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LIBRARY OF CONGRESS. 

Chap. .^Copyright No. 

Shelf_A2>3 



UNITED STATES OF AMERICA. 



ATLAS 

OF 

SYPHILIS 

AND THE 

VENEREAL DISEASES 

INCLUDING 

A BRIEF TREATISE ON THE 

PATHOLOGY AND TREATMENT 

BY / 

PROF. DR. FRANZ MRACEK 

of Vienna 



AUTHORIZED TRANSLATION FROM THE GERMAN 



EDITED BY 



L. BOLTON BANGS, M.D. 

Consulting Surgeon to St. Luke's Hospital and the City Hospital, New York; 

late Professor of Genito-Urinary Surgery and Venereal Diseases, New 

York Post-Graduate Medical School and Hospital 



With 71 Colored Plates 



PHILADELPHIA 
W. B. SAUNDERS 

925 Walnut Street 
1898 






9398 

Copyright, 1898, 
BY W. B. SAUNDERS. 



1898. 

JUL -8 11 




TWi 3EIVED. 



ELECTROTYPED BY 
WESTCOTT & THOMSON, PHILADA. 



PRESS OF W. B. SAUNDERS, 
PHILADA. 



LIST OF ILLUSTRATIONS. 



Plate 1. 


Plate 2. 


Plate 3. 


Plate 4. 


Plate 5. 


Plate 6a. 


Plate 6b. 


Plate 7. 


Plate 8. 


Plate 9. 


Plate 10. 


Plate 11. 


Plate 12. 


Plate 13. 


Plate 14. 


Plate 14a. 


Plate 15. 


Plate 16. 


Plate 17. 


Plate 18. 


Plate 19. 


Plate 20. 


Plate 21. 


Plates 22, 


Plate 24. 


Plate 24a. 


Plate 25. 


Plate 26. 



Sclerosis in the coronary sulcus of the penis. 

Sclerosis in the pubic region. 

Sclerosis on the anterior surface of the scrotum. 

Sclerosis on the right labium. 

Ambustiform sclerosis and indurative edema of the left 

labium. 
Ulcerative sclerosis in the vaginal portion of the cervix. 
Sclerosis in the vaginal portion of the cervix. 
Two ulcerative scleroses on the os uteri. 
Sclerosis on the lower lip. 
Sclerosis at the right angle of the mouth. 
Sclerosis of the tongue. 
Sclerosis of the right tonsil. 
Indurative syphilitic edema. 
Eecent macular eruption (roseola) over the entire surface of 

the body. 
Large macules mixed with papules, scattered over the entire 

body. 
(Dorsal view.) 
Erythema figuratum. 

Erythema figuratum (erytheme circinee — Fournier). 
Syphilitic papules distributed over the entire body. 
Papulopustular Syphilide — Jaundice. 
Small, aggregated papules (lichenoid Syphilide, relapsing 

form). 
Papulosquamous Syphilide. 
Papular orbicular Syphilide. 
23. Irregularly distributed papular Syphilide. 
Leukoplasia of the neck. Papules on the genitalia. 
(Front view.) 

Flat, glistening papules on the forehead and face. 
Syphilitic alopecia areolaris. 

7 



8 



LIST OF ILLUSTRATIONS. 



Plate 26a. 
Plate 27. 
Plates 28, 
Plates 29, 

Plate 30. 
Plate 31a. 
Plate 31&. 
Plate 32. 
Plate 33. 
Plate 34. 
Plate 35. 

Plate 36. 

Plate 37. 
Plate 38. 
Plate 39. 

Plate 40. 

Plate 41a. 

Plate 41&. 
Plate 42a. 
Plate 42&. 
Plate 43a. 
Plate 43&. 
Plates 44, 
Plates 46, 



Plate 48a. 
Plate 48&. 
Plate 49. 
Plates 50, 
Plate 51. 
Plate 52. 

Plate 52a. 
Plate 53. 

Plates 54, 



Papules on tbe hairy scalp. 

Small pustules on the face. 

28a, 28b. Pustular Syphilide. 

29a. Proliferating pustular ulcers (frambesia or yaws) on 

both calves. 
Psoriasis syphilitica plantaris. 
Eroded papules between the toes. 
Papules and fissures between the toes. 
Syphilitic paronychia of both hands. 
Proliferating, eroded papules of diphtheritic character. 
Proliferating papules. 
Proliferating papules on the labia majora, in the genito- 

crural fold, and on the perineum as far as the anus. 
Proliferating papules on the labia majora, on the perineum, 

and about the anus. 
Hypertrophic papules and folds about the anus. 
Old annular papules that have begun to heal in the center. 
Diphtheritic papules on the mucous membrane of the os 

uteri and vagina. 
Diphtheritic papules on the mucous membrane of the upper 

lip and left side of the mouth. 
Infiltration and superficial necrosis of the mucosa and sub- 

mucosa of the upper lip. 
Ulcerating papules and incipient leukoplakia of the tongue. 
Elevated, coalescent papules on the hard palate. 
Leukoplasia (psoriasis) linguse. 
Condylomatous iritis. 

Gummatous tarsitis of the left eye. Trachoma. 
45. Syphilitic frambesia (yaws). Syphilis praecox. 
46a, 47. Gummatous ulcers on the labia majora, the pos- 
terior commissure, the right labium minus, and 
the vagina. 
Gummatous ulcer of the left nipple. 
Gumma of the breast. 
Syphilitic rupia. 

50a. Serpiginous, gummy ulcers. 
Serpiginous, gummy ulcers of the right calf. 
Cutaneous gumma on the dorsum of tbe foot. Gumma of 

the pharynx. 
Ulcerative gummata of the pericranium. 
Gumma in the glands of the neck, with destruction of the 

integument. 
54a. Gummatous ulcers of the skin and inguinal glands. 



LIST OF ILLUSTRATIONS. 



Plate 55. 
Plate 56a. 
Plate 566. 
Plate 57. 
Plate 58. 
Plate 59. 
Plate 60a- 
Plate 61. 
Plate 62. 

Plate 63. 

Plate 64. 

Plate 65. 
Plate 66. 
Plate 67. 
Plate 68. 



Plate 69. 
Plate 70. 
Plate 71. 



Gummatous disease and necrosis of the soft parts. 

Destruction of the soft palate by gummatous ulceration. 

Gumma on the posterior wall of the pharynx. 

Gummatous glossitis. 

Papulopustular exanthema. Hereditary syphilis. 

Papulovesicopustular exanthema. Hereditary syphilis, 
-c. Hereditary syphilis. 

Venereal ulcers on the foreskin and on the head of the penis. 

Contagious, coalescent venereal ulcers on the skin of the 
penis. Adenitis of the right inguinal glands. 

Paraphimosis from venereal ulcer on the foreskin. Inflam- 
matory edema. Suppurative adenitis in both groins. 

Suppurative lymphangitis of the dorsum penis (bubonulus 
Xisbethi), with necrosis of the integument. 

Abscess of the left gland of Bartholin. 

Gonorrhea. Cavernitis. 

Condylomata acuminata. 

Condylomata acuminata on the coronary sulcus and on the 
inner layer of the foreskin, which is inflamed and 
necrotic along the left border. 

Condylomata acuminata at the os uteri. 

Subcutaneous hemorrhage into the skin of the penis. 

Molluscum contagiosum (moniliforme [bead-like]). 



EDITOR'S PREFACE. 



Thoroughness has always been granted as one of the 
chief attributes of German teachers. The present volume, 
in the opinion of the editor, shows another trait no less 
characteristic, but which is perhaps not so generally con- 
ceded. It is a certain strong practical sense in selecting 
the material and presenting it in the form best fitted to 
the needs of those for whom it is intended. On the lat- 
ter point the author has defined the purpose of his work 
in his preface. Making some allowance for local customs 
and conditions, especially in the matter of treatment, 
the book will, it is believed, prove a thoroughly practical 
manual for the every-clay use of the practising physician. 

The translator has endeavored to follow the German 
text as faithfully as possible, and has ventured to depart 
from the original only Avhen the needs of the language ap- 
peared to justify such a departure. The translation will 
therefore be found to be a conscientious reproduction of the 
author's ideas in concise, smooth, and graphic phraseology. 

For the sake of convenience the names of drugs and 
certain technical terms have been made to conform to the 
current English expressions, and in the prescriptions the 
equivalent amounts in apothecary's weight have been 
added in parentheses after the number of grams. 

A short index has been added, which is to be regarded 
rather as a supplement to the table of contents and the 
list of illustrations. 



PREFACE 



In complying with the publisher's request, made to me 
two years ago, to prepare an Atlas of Venereal and Syph- 
ilitic Diseases, I have endeavored to produce a book which 
should be within the reach of a wider circle of readers, 
as both the scope and the cost of the pictorial works 
hitherto published on the subject necessarily restrict their 
influence to a comparatively small number. To carry out 
this plan it was found necessary to select those diseases 
which are of the most frequent occurrence and greatest 
practical importance, omitting such as interest only the 
specialist. The same principle controlled the composition 
of the text. The clinical material is drawn chiefly from 
my ward in the K. K. Rudolfsspital in Vienna. I have 
to express my thanks to Dr. Braun, Director of the 
Northern Austrian Foundling Asylum, for two cases of 
hereditary syphilis ; to (Prof.) Dr. Bergmeister, " Primar- 
arzt," for two cases of syphilitic eye-disease, and to 
(Prof.) Dr. E. Lang for a case of disease of the hairy 
scalp. 

Mr. Schmitson mastered the difficult problem of inter- 
preting and reproducing the various clinical pictures in 
an amazingly short time, and has turned out a truly 
admirable set of water-colors, the reproduction of which 
by the publishing house has been done in the most 
exemplary manner. 

13 



14 PREFACE. 

In the work of sifting the case-histories and preparing 
the material I have been most ably and zealously aided 
by my assistant, Dr. Grosz. 

To all these gentlemen I wish to express my hearty 
thanks, and I trust that the present work may meet with 
a kind reception among those for whom it is intended. 

Dr. MRACEK. 

Vienna, November, 1897. 



CONTENTS. 



PAGE 

Introduction 1 

The Primary Stage of Acquired Syphilis. 

Conditions of Infection 4 

Channels of Infection 5 

The first Phenomena that appear after Syphilitic Infection ... 7 

Swelling of Lymph-glands 10 

Phimosis and Paraphimosis 10 

The Secondary Stage of Syphilis. 

Prodromal Symptoms during the Eruptive Period 11 

The Syphilitic Exanthemata 13 

The Macular Syphilide 13 

The Papular Syphilide 15 

The Pustular Syphilide 17 

Syphilides with Cutaneous Hemorrhages 19 

Abnormal Color-changes 20 

Diseases of the Hairy Scalp 21 

Diseases of the Palms of the Hands, Soles of the Feet, the Fingers, 

and the Toes, 22 

Secondary Syphilitic Phenomena in the Genitalia and about the 

Anus 23 

Diseases of the Buccal Mucous Membrane 26 

The Tertiary Stage of Syphilis. 

Introduction 28 

Gumma of the Skin and Subcutaneous Cellular Tissue 31 

Tertiary Syphilis of the Motor Apparatus 35 

Tertiary Syphilis of the Lymphatic Apparatus 38 

Tertiary Syphilis of the Digestive Tract 41 

Tertiary Syphilis of the Eespiratory Tract 49 

Tertiary Syphilis of the Circulatory System 51 

Tertiary Syphilis of the Genito-urinary Apparatus 53 

Tertiary Syphilis of the Eye 57 

Tertiary Syphilis of the Central Nervous System 60 

15 



16 CONTENTS. 

PAGE 

Hereditary Syphilis 64 

The Treatment of Syphilis 72 

Primary Forms 72 

Local Treatment of the Secondary and Tertiary Lesions 75 

General Treatment 79 

The Care of the Mouth before and during Mercurial Treatment . 81 

Mercurial Treatment of Syphilis 82 

Use of the Iodids in Syphilis 86 

Medicinal Woods 88 

Venereal Ulcers. 

Complications : Lymphangitis, Adenitis 92 

Treatment of Venereal Ulcers 96 

Gonorrhea. 

Gonorrhea of the Genitalia 101 

Complications 104 

Condylomata Acuminata 107 

Treatment of Gonorrhea and its Complications 109 



PLATE 1. 
Sclerosis in the Coronary Sulcus of the Penis. 

Present Condition. — On the dorsal aspect of the neck a 
sclerosis measuring about 1 cm. in diameter; the surface is 
necrotic, the base and surrounding tissue moderately infiltrated. 
Perceptible swelling in the inguinal glands; on the trunk a 
pale, slightly raised eruption. 

Sch. J. ; admitted Nov. 24, 1895. Says he had his last coitus 
Oct. 4th ; the sore on the penis developed four weeks later. 
Has always been healthy. 



Tab. 1. 




LithÄnsT .v. F. Reirhhold. München . 



PLATE 2. 
Sclerosis in the Pubic Region. 

Present Condition. — In the pubic region there is a sclerosis 
about the size of a hazelnut which is quite deep ; the floor is cov- 
ered in part with pus and in part with pale granulations ; the 
edges are sharp, tough and infiltrated, and surrounded by a zone 
of inflammation. The inguinal glands are greatly enlarged ; the 
axillary and cervical, only moderately so. 

M. T., 34 years old, works in a gas-factory ; admitted June 7, 
1896. In the beginning of May a glowing piece of coke fell on 
the patient's bare breast ; in attempting to shake it out of his 
clothing he burnt himself in the pubic region. Two weeks later 
he had coitus. He had no suspicion of the true nature of his 
disease. On June 20th a dark-red, papular Syphilide appeared 
on the body. 

Local treatment and twenty-five inunctions effected a cure. 



CM 



OS 




PLATE 3. 
Sclerosis on the Anterior Surface of the Scrotum. 

Present Condition. — On the scrotum, below the angle 
formed by the penis (penoscrotal angle), is seen a sclerosis a 
little larger than an almond. The surface is ulcerated, the base 
and edges infiltrated. The rest of the genital region, as well as 
the skin on the trunk and extremities, is covered with recent 
papules as large as lentils. The older of these papules already 
show desquamation on the surface. 

W. A., 28 years old, mail-driver; admitted Nov. 1, 1895. The 
patient says he paid no attention to the sore on the scrotum at 
first. It began to be more noticeable four weeks ago ; the erup- 
tion appeared only six days ago. 

After local treatment with gray plaster and a course of 
twenty-five inunctions the sclerosis healed completely, the in- 
filtration at the base softened, and the eruption disappeared. 
The patient was discharged on Dec. 2d, after thirty-two days' 
treatment. 



PLATE 4. 
Sclerosis on the Right Labium Majus. 

The right labium majus is moderately swollen and edematous. 
On the external surface of the lowest segment there is a hard 
lump about as large as a penny ; the crater-like center is covered 
with pus and discharges quite freely. 

In addition to the sclerosis described, the patient exhibits 
a macular Syphilide on the trunk and a lenticulo-papular erup- 
tion on the thighs and nates. The inguinal, as well as the cervi- 
cal and axillary lymph-glands on both sides of the body are 
involved. 

K. C, 20 years old; admitted Aug. 16, 1896. Her first 
venereal attack, which she says began three weeks ago (?). 

After fifteen inunctions the sclerosis healed, the edema dis- 
appeared, the eruption became less angry (paler), and the infil- 
tration about the site of the sclerosis as well as the glandular 
swelling diminished. 



PLATE 5. 

Ambustiform Sclerosis and Indurative Edema of the Left 
Labium Majus. 

Present Condition. — The entire left labium majus shows a 
livid discoloration and is considerably swollen and indurated. 
About the middle is an ulcer with hemorrhagic floor and 
slightly eroded edges, resembling a wound made by a red-hot 
instrument (sclerosis ambustiformis). The inguinal glands, 
especially on the left side, are swollen, and the axillary and 
cervical glands slightly enlarged. Patient had been suffering 
from insomnia for a week. Later in the course of the disease 
a roseola appeared on the trunk. 

H. M., 21 years old, cashier ; admitted Oct. 13, 1896. The 
patient says she noticed her condition only a week ago. Last 
coitus seven weeks ago. 

After the use of inunctions the eruption disappeared, the 
glandular swelling diminished, the sclerosis healed, and the 
indurative edema was reduced to an elastic thickening of the 
labium. 



Tab. 5. 





■ 



Lnh.Ami x F He ichhold . München 



PLATE 6a. 
Ulcerative Sclerosis in the Vaginal Portion of the Cervix. 

The vaginal segment enlarged as a whole ; the os slightly con- 
tracted by scar-tissue. On the anterior lip, close to the os, is a 
slightly raised sclerosis, the floor of which presents a diphther- 
itic appearance and is marked in places by small hemorrhages. 
On palpation a lump as hard as cartilage can be plainly made 
out in the vaginal portion. There is a shallow erosion on the 
posterior lip. 

B. A., 22 years old. The patient has given birth to one child. 
She first became aware of her disease when a sclerosis, similar 
to the one described, appeared on one of the labia. She knows 
nothing of the sclerosis in the vaginal portion. Last coitus 
seven weeks ago, last but one eighteen months ago. 

Later in the course of the disease a macular Syphilide made 
its appearance. Inguinal, cervical, and axillary glands enlarged. 

Inunction treatment. 

The sclerosis was excised and examined under the micro- 
scope. 1 

See Vierteljahr schrift für Dermatologie, 1881, page 57 et seq. 



PLATE 6b. 
Sclerosis in the Vaginal Portion of the Cervix. 

Present Condition. — Vagina pale and distended ; secretion 
scanty. Cervix large and cylindrical. On the anterior lip is a 
circular, sharply circumscribed ulcer about as large as a penny, 
with purulent floor. Surrounding tissue much inflamed. Glands 
palpable everywhere. 

P. C, 43 years old, prostitute ; admitted April 15, 1896. Says 
she has been ill six days. 

Treatment. — White-precipitate ointment. Cicatrization 
May 4, 1896. 



Tab. 6. 





I) 



liifiAnsi.v. F. Reichhold . München 



PLATE 7. 
Two Ulcerative Scleroses on the Os Uteri. 

The cervix as a whole is swollen and edematous, and shows 
several cicatricial contractions, the result of former confine- 
ments. On symmetrical areas of the anterior and posterior lips 
are two sharply circumscribed scleroses, with raised edges and 
purulent floor. The surrounding tissue is very hard to the 
touch. The secretion is serous in character and not particularly 
copious. 

G. M., 24 years old. The patient was not aware of her dis- 
ease, but came to be treated for papules in the vestibule. In 
addition to the symptoms described, the patient had a slight 
macular eruption and glandular enlargement. 

Patient was subjected to inunctions. 



Tab. 7. 




. F.Reichliold, München 



PLATE 8. 
Sclerosis on the Lower Lip. 

Present Condition.— On the lower lip, to the right of the 
middle line, is an ulcer, about 1.5 cm. in thickness, the center 
somewhat depressed, with slightly raised edges. There is some 
infiltration and the ulcer is breaking down. 

The patient, K. M., 21 years old, does not know the cause of 
this ulcer, which appeared about four months ago and has been 
steadily growing larger. The only other symptom is swelling 
of the submaxillary glands ; the cervical, axillary, and inguinal 
glands are also enlarged ; the genitalia are intact. 

The ulcer healed after the application of gray plaster and 
about thirty inunctions. 



Tab. 8. 




lithinst.v. F Re ichhold , München 



PLATE 9. 
Sclerosis at the Right Angle of the Mouth. 

N. P., 29 years old, blacksmith; admitted Oct. 30, 1895. 
Eight weeks ago the patient first noticed a sore at the right 
angle of the mouth, which slowty but steadily increased in size. 
Five weeks ago the right cheek and the right submaxillary 
region began to swell. The patient does not know the cause of 
his disease; but he says that at the time it began there was a 
man in the shop where he works who was suffering from a 
chancre. For the past two weeks he has had severe nocturnal 
headache. 

Present Condition. — In the mucous membrane of the right 
angle of the mouth an oval, cup-shaped ulcer, over | cm. long, 
covered with pus. The right side of the face is swollen. The 
submental and submaxillary lymph-glands are enormously en- 
larged. The other lymph-glands are also involved, but not to 
the same degree. Maculopapular Syphilide on the trunk and 
extremities. 

Cured after twenty-five inunctions. 



Tab. 9. 




Lith.Anst v. Y. Reiohhold , München 



PLATE 10. 
Sclerosis of the Tongue. 

Fr. Th., 25 years old, working-woman; admitted Oct. 22, 
1896. An ulcer of unknown origin appeared on the tongue 
a month ago. 

Present Condition. — The right margin of the tongue ex- 
hibits a hard nodule about as large as a bean, partly embedded 
in the substance of the tongue and partly rising above its level. 
In the center is a flat, oval ulcer, the floor of which is covered 
with a grayish-white secretion. The submaxillary glands on the 
right side are enlarged to the size of a pigeon's egg and painful 
on pressure. Cervical and axillary glands can be plainly felt. 
Genitalia normal. A few scattered macules on the trunk. 

Nov. 2. Papules have made their appearance between the 
macules. Headache. 

Subsequent Course. — After twenty inunctions complete 
regeneration of the nodule on the tongue, and disappearance 
of all other specific symptoms. 

Nov. 28. Discharged cured. 











■p^ 



PLATE 11. 
Sclerosis of the Right Tonsil. 

W. W., 26 years old, roofer ; admitted June 29, 1896. Patient 
says he has always been healthy ; since May 13th has noticed 
a swelling of the right tonsil and pain on swallowing. 

Present Condition. — The right tonsil is larger than a 
pigeon's egg and reaches almost to the middle line, forcing 
the palatoglossal and palatopharyngeal arches far apart. It 
shows considerable infiltration and is covered with partly 
necrosed ulcers. The mucous membrane of the adjoining 
tissues is inflamed and slightly swollen. The inflammation 
extends as far as the uvula on the left side, and in front as far 
as the anterior border of the soft palate. Under the angle 
of the jaw, on the right side, is a slightly movable tumor, about 
as largo as a hen's egg, which corresponds to the submaxillary 
gland. The middle cervical glands and the supraclavicular 
glands on the right side are as large as beans or hazelnuts, 
easily movable, but not painful. The left middle cervical and 
the axillary and inguinal glands are also palpable, but not 
swollen. 

July 1. A roseolar eruption over the entire trunk. The 
necrotic covering of the sclerosis has fallen off. 

July 5. The Syphilide and the glandular swelling increase. 
Granulation is forming in the sclerosis. 

Treatment. — Gargles. The sclerosis was painted with tinct- 
ure of iodin. Twenty inunctions. 



Tab. 11. 




KReHilioM.Müitclim 



PLATE 12. 
Indurative Syphilitic Edema. 

J. S., 20 years old, butcher. Under treatment from Oct. 
24 to Dec. 9, 1890. 

Two months ago the patient contracted a sore at the lower 
margin of the prepuce. Within a week the entire penis was 
swollen and inflamed. Three weeks ago the scrotum began to 
swell. The prepuce, which accordingly has been swollen for 
seven weeks, could not be pushed back by the patient, so that 
he can give no account of the subsequent course of the wound. 

Present Condition. — Edematous phimosis of the prepuce. 
Lymphangitis and edema of the skin of the entire penis. 
Indurative edema of the scrotum with superficial erosions. 
Bilateral inguinal lymphadenitis. General disease of the lym- 
phatic system. Both tonsils are enlarged and covered with 
diphtheritic papules. Psoriasis plantaris. On the trunk a 
papular Syphilide in process of regeneration. Length of the 
penis, 13 cm. ; circumference taken about the center, 11.5 
cm. ; circumference of the scrotum, measured in the sagit- 
tal direction from the root of the penis to the perineum, 26 
cm.; circumference of the scrotum, measured in the frontal 
direction from one inguinal fold to the other, 30 cm. The skin 
of the scrotum is dark red, hot and infiltrated. On the scrotum 
and on the penis the skin is coming off in single, attenuated 
layers ; a few erosions on the scrotum. The integument of the 
scrotum is so thick and infiltrated that the testicles cannot well 
be made out by palpation. 

Treatment. — Irrigation of the preputial sac. Compresses 
wet in aluminum acetate solution. On Oct. 30th inunctions 
were begun, and the swelling and infiltration of the skin of 
the scrotum and penis began to subside. Exposition of the 
prepuce revealed a shallow scar, as large as a pea, on the inner 
surface of the prepuce and on the lower aspect of the glans. 
Circumcision. Entire disappearance of all the symptoms after 
thirty inunctions. 






f 



Tab. 3 2. 














PLATE 13. 

Recent Macular Eruption (Roseola) over the Entire Surface 
of the Body. 

The skin of the entire body is thickly covered with red spots, 
of a darker color on the dependent portions of the body than 
about the trunk, neck, and face ; the spots are not shiny and 
do not desquamate. The soles of the feet and palms of the 
hands exhibit a brownish, papular eruption (psoriasis plantaris 
et palmaris). 

The prepuce is indurated and shows the scar of a sclerosis. 
The inguinal, cervical, and axillary glands are enlarged. 

B. L., 23 years old, laborer; admitted Aug. 4, 1897. The 
patiejit states that he was discharged from a hospital a month 
ago, after the sore on his penis was cured, without being sub- 
jected to any general treatment. He is unable to give the 
exact date of his infection (a little more than two months ago). 

After being treated with inunctions for thirty days the patient 
was discharged cured. 



Tab. 13. 




LithAnst.v.y Reinhhold. Münchni 



PLATES 14, 14a. 

Large Macules Mixed with Papules, Scattered over the 
Entire Body. 

H. S., 19 years old; admitted Jan. 27, 1896. The history, 
as given by the patient, is extremely inaccurate, and amounts 
to this, that he has been ill three months and has done nothing 
so far to cure himself. 

Present Condition. — A livid, somewhat infiltrated scar, the 
result of the primary lesion, on the outer layer of the prepuce. 
Moist papules in the coronary sulcus of the penis and about the 
anus. An abundant macular Syphilide scattered over the trunk 
and extremities. Here and there among the macules are seen 
large, shiny papules, their reddish-brown color contrasting with 
the livid hue of the macules. The soles of the feet exhibit 
dirty yellow papules (psoriasis plantaris). Alopecia and slight 
desquamation of the hairy scalp. On the forehead a maculo- 
papular Syphilide. Both tonsils are enlarged and covered with 
coalescent, suppurating ulcers (papules). 

Treatment. — Labarraque's solution externally. Inunctions. 

Black Plate (PI. 14 a) : Dorsal view, showing the widespread 
large macular Syphilide. Colored Plate : Right forearm, with the 
same large macular Syphilide. 



Tab. 14. 




LrtliAm.v. F. RpwWiold . München 



Tab. 14 a. 




PLATE 15. 



Erythema Figuratum. 

H. J., 42 years old, saloon-keeper ; admitted July 12, 1896. 
Became infected eighteen months ago, at which time he was 
subjected to inunctions at this hospital. Since then he has had 
several relapses, taking the form of papules on the mucous 
membranes, which were treated with milder remedies (internal 
administration of mercurial preparations, potassium iodid, and 
external applications of chromic acid). He says the eruption 
appeared a week ago. The patient is a moderate drinker and 
smoker. 

Present Condition. — On the dorsum of the penis is an infil- 
trated scar as large as a penny. The lymph-glands which can 
be felt are spindle-shaped. About the middle of the right 
border of the tongue is a papular efflorescence about as large as 
a pea, with ulcerated surface. Otherwise the mucous mem- 
branes are free from disease. The skin of the trunk and of the 
upper extremities is covered with a pale-red exanthema, arranged 
in sinuous figures formed by the confluence of circular erup- 
tions. The rash is distributed over the extensor surfaces of the 
arms and over the trunk, being more distinct on the sides of 
the thorax than on the back and buttocks. The graceful figures 
stand out very plainly after the naked body has been exposed 
to the air. The patient complains of headache, worse at night. 
Psychical condition intact. Pupillary reaction and tendon- 
reflexes normal. 

Treatment. — Potassium iodid \ . _ 1 m , 
Potassium bromid J ^ & 



xv). 



To be taken at night. 



Cured. 




Tab. 15. 












PLATE 16. 
Erythema Figuratum. 

(Erytheme circinee — Fournier.) 

E. B., 26 years old, clerk; admitted Dec. 21, 1896. The 
specific infection occurred in February of the present year; 
the patient was treated with injections at the time. For the 
past two weeks he has had difficulty in swallowing ; he has no 
knowledge of any rash. 

Present Condition. — Eroded papules on both tonsils. The 
latter, as well as the pillars of the fauces and the posterior wall 
of the pharynx, are swollen and inflamed. The entire lym- 
phatic system is diseased. A pale-red eruption appears dis- 
tributed almost symmetrically over the skin of the trunk and 
extremities. The individual patches of the eruption are circu- 
lar in shape and vary in size from a penny to a dollar. By the 
confluence of adjoining patches the eruption assumes the form 
of festoons or garlands, the general arrangement of the figures 
corresponding to the slant of the ribs on the back, chest, and 
sides of the thorax. The face, palms of the hands, and soles of 
the feet are free. 

Cured after twenty-five inunctions. 



Tab. 16. 










r.FR*icWiöld. Münch 



PLATE 17. 
Syphilitic Papules Distributed over the Entire Body. 

L. M., 30 years old, laborer; admitted July 4, 1897. The 
patient says he performed his last coitus two months ago. 
Immediately afterward he noticed a sore on the foreskin. The 
eruption he noticed eight to ten days ago. Has had no treat- 
ment so far. 

Present Condition. — The skin of the entire body is of a 
brownish hue and covered with copper-colored nodules as large 
as lentils. The eruption is situated mostly at the sides of the 
thorax, on the abdomen, and on the flexor surfaces of the ex- 
tremities. Most of these papules already show a whitish dis- 
coloration of the epidermis at the apex, which can be removed 
in some of them by very light abrasion with the finger-nail. 
All the lymphatic glands are moderately enlarged. On the 
dorsal aspect of the heck of the penis is a livid, recently healed, 
sclerosis, surrounded by a good deal of induration and infiltra- 
tion. The mucous membranes, palms of the hands, and soles 
of the feet are not involved. A few papules are seen on the 
face, at the roots of the hair. The hairy scalp shows slight 
seborrhea, but no distinct papules. 

Treatment. — Antiseptic mouth-wash ; baths ; twenty-five 
inunctions. Cured. 



Tab. 17. 






m 



7 




"X 



Lirh.Ansi v. Y RpK-hhrW . Münr lien 



PLATE 18. 
Papulopustular Syphilide. Jaundice. 

M. S., 24 years old, nurse. Under treatment from Feb. 11 to 
March 20, 1897. The patient says she had jaundice five weeks 
before entering the hospital ; the eruption appeared only dur- 
ing the last week. She has suffered a good deal lately with 
frontal headache, especially at night; also complains of sore 
throat. Last coitus three months ago. 

Present Condition.— On the right labium majus a sclerosis 
as large as a hazelnut, with ulcerated surface. General gland- 
ular enlargement. The skin and mucous membranes, where- 
ever visible, present an intense yellow discoloration and are 
thickly covered with innumerable papules, varying in size from 
a millet-seed to a lentil. Here and there, especially on the 
back and in the intermammillary region, are numerous pus- 
tules covered with hemorrhagic crusts. Eecent eruption of 
psoriasis plantaris. Mucous membrane of the mouth intact. 
The face wears an expression of suffering. Violent headache. 

Treatment. — Labarraque's solution locally. Antiseptic 
mouth-wash. 

Feb. 15. Patient very much prostrated ; complains of violent 
headache, especially at night; temperature normal; percussion 
and palpation bring out no enlargement of liver or spleen. 
Inunctions. 

After fifteen inunctions the jaundice disappeared entirely, the 
patient began to feel better, and the specific symptoms began to 
subside, the papules and pustules being replaced by pigmenta- 
tion. After thirty inunctions the patient was discharged cured 
on March 20th. 



Tab. 18. 






rf/f 






LitLAnsi v. Y. R? ichhold . München 



PLATE 19. 

Small, Aggregated Papules (Lichenoid Syphilide, Relapsing 

Form). 

S. A., 19 years old, seamstress ; admitted Jan. 24, 1896. Patient 
was treated for syphilis in Sept. and Oct., 1895. The present 
trouble developed a month ago. 

Present Condition, — On both labia majora and in the 
genitocrural fold on both sides are seen papules as large as 
peas and elevated above the surrounding level. Over the 
sacrum and on the nates, small aggregated papules. Some of 
the papules are desquamating, others show a reddish-brown 
pigmentation. Similar patches are seen over the knee-joint, 
on the lower abdomen, and at the back of the neck. Moderate 
itching in the affected parts. 

Cured after twenty inunctions of 5 g. (3jss) each. 



** 



Tab. 19. 






*•* 



^ 






i 



• 



«* 



»®*% 



\j 



M 



^ 









LrihJtasiv. F RfM'-hhoM, Münclmi 



PLATE 20. 

Papulosquamous Syphilide. 

T. J., 34 years old, hostler ; admitted March 27, 1896. Toward 
the end of June, 1895, four weeks after coitus, the patient had 
an ulcer on the penis. He then had a private physician, and 
was treated with yellow-precipitate ointment and sublimate 
baths locally. After the ulcer healed the patient again indulged 
in sexual intercourse ; three weeks later an eruption appeared 
over the entire body (from his description a macular and papu- 
lar Syphilide). On Aug. 20, 1895, he applied for admission to 
the general hospital, and was treated until Oct. 31st. He was 
subjected first to twenty-three inunctions with calomel, and 
then to forty-seven inunctions with gray ointment. On Nov. 
24th patient applied for admission to the Rudolfspital. He 
then complained of pains in the head, in the epigastrium, and 
in the thorax. The patient was pale; the skin of the trunk 
was thickly covered with livid and brownish patches as large 
as a pea, the remains of an old Syphilide ; the epidermis over 
most of the patches is marked by fine furrows. Inguinal, axil- 
lary, and cervical glands enlarged. Incipient leucodermia 
colli. Pharyngitis. The internal organs were normal. On 
Dec. 11th a tassel-shaped eruption appeared on the forehead. 
On Dec. 18th the tassel disappeared, leaving a livid spot, and 
appeared in another place. At the same time several papules 
appeared, disposed in a circle about the left nostril, and also 
another papular eruption on the throat. The gums are eroded. 
Gingivitis. Seborrhoea capitis. Alopecia. General neuras- 
thenia. On Dec. 24th single pustules appeared on the head. 
On Jan. 2d the patient felt completely cured, and was, at his 
own request, discharged from the hospital. On March 27, 1896, 
he again asked to be admitted to the hospital. Examination 
revealed the following condition : in addition to the remains of 
the old Syphilide, which existed during his former stay at the 
hospital, the entire body is now covered with a new eruption ; 
the center of the papules, which vary in size from a pea -to a 
bean, consists of a raised, whitish scab, while the margin is of a 
light-red color. In some places the central scab has fallen off, 
leaving only a livid, red patch, slightly raised above the level of 






m 



Tab. 20. 










h 




'. Y. RjemlihoW , München 



the skin. The center of these patches is badly degenerated and 
converted into a hemorrhagic wound, and around it are grouped 
thick clusters of small, miliary papules. The isolated, small 
nodules show a slight whitish discoloration at the apex, but no 
desquamation. In addition, the remains of the old Syphilide 
are seen here and there (at the top of the illustration, for in- 
stance) in the form of light, reddish-yellow patches of epidermis 
marked by delicate striations. The lower part of the navel is 
occupied by a phagedenic, moist papule. The general color of 
the skin is dirty yellow, with here and there irregular lighter 
areas, the remains of former eruptions. Ulcerating papules on 
the scrotum ; papules on the mucous membrane of the mouth 
and of the lower lip, and on both tonsils. 
Treatment. — Mixed. Cure. 



PLATE 21. 
Papular, Orbicular Syphilide. 

M. E., servant-girl, 26 years old ; admitted Oct. 1, 1895. The 
patient became aware of her syphilitic disease by accident, a 
police-surgeon calling her attention to it on the occasion of her 
being incarcerated, although she knew that an eruption had 
begun to develop in the genital region for a year, and on the 
lower limbs and on the neck for the last five months. She, 
however, attached no importance to it and did nothing for it. 
She has never given birth, menstruates regularly, and says that 
she had her last coitus more than a year ago. 

Present Condition. — In both genitocrural folds, at the 
edges of both labia majora, and about the anus are seen prolif- 
erating papules, some of which have run together. Part of the 
trunk is covered with the pigmented remains of a papulo- 
serpiginous Syphilide, the rest by an irregular (figurate) Syphi- 
lide made up of large macules. On the legs is a lichenoid, 
brownish-yellow Syphilide, arranged in groups. On the inner 
aspect of each thigh is an elliptical, orbicular Syphilide. The 
margin is composed of small, lichenoid papules surrounded by 
a coppery halo ; the center is brown, with a shade of gray, and 
the epidermis is in part undergoing desquamation. Above, 
the line of small papules is irregular, so that the margin of the 
entire ellipsoid figure appears broken. In addition, all the 
lymph-glands are swollen; the mucous membranes are free. 

After local treatment with sublimate and gray plaster, and 
forty inunctions, the Syphilide disappeared, leaving some pig- 
mentation. The patient was discharged cured after having 
been under treatment sixty-five days. 



H 



a 



■ 



1 



1 









/ 



PLATES 22, 23. 

Irregularly Distributed Papular Syphilide. 

A. M., 36 years old ; admitted June 23, 1896. Four months 
ago the patient first noticed an eruption of small nodules on 
her arms. These nodules degenerated and formed shallow 
ulcers, which dried up six weeks ago. The group on the 
left side of the neck, at the hair-line, and the patches in the 
left eyebrow developed six months ago. 

Present Condition. — The inner portion of the right eyebrow 
(PL 22) presents a group of hard, shiny papules ranging in size 
from a lentil to a pea ; between the two larger ones is a tough 
scar surrounded by infiltration. 

At the edge of the hair, in the neck, is a group of copper- 
colored papules, closely crowded together for the most part, 
resting on an infiltrated base. The center is occupied by 
desquamating scars continuous with the bands of - infiltrated 
tissue, which are partly covered with scabs and appear ar- 
ranged in folds; distinct, isolated nodules, somewhat larger 
than lentils, are disposed about the periphery. Below this 
is another group, the center of which consists of a purulent 
infiltrate, with infiltrated, desquamating edges, surrounded by 
fresh, pale nodules. A third patch presents a keloid appear- 
ance, the infiltration, which is similar to that in the center of 
the papules, being depressed in the center and at the edges. 
Other similar patches are found on the extremities. 

In the gluteal folds and in the prolongation of the right 
labium majus is a group of nodules as large as the head of a 
pin, some of which are not eroded. Other papular eruptions, 
similar to those shown in the illustration, are scattered more 
or less profusely over the entire body ; some of these show the 
crater-like central scar, others merely pale nodules, varying in 
size from the head of a pin to a lentil or a pea, resting directly 
on the skin. 

Wherever the infiltrated areas have coalesced, the entire skin 
is converted into a plaque of infiltrated tissue. The crater-like 
scars are tough, with everted, glistening edges, and resemble 
keloids. The lymphatic glands, although not swollen, are hard 
to the touch. The patient is pale, but not anemic. She has 
been pregnant seven times; one child born at term and six 
abortions in the third or fourth month ; she has menstruated 
regularly for the last four years. The patient has always been 
well, comes of a healthy family, and has no knowledge of her 
disease. 



Tab. 22. 




Lüh.Aiist w F. Reiclihold, München 



Tab. 23. 




W > 



■ ■•y)\\\o\(\.\\i\uchm 



PLATES 24, 24a. 
Leukoplakia of the Neck. Papules on the Genitalia. 

A. B., 18 years old, servant-girl. Has never had a venereal 
disease. In the beginning of Dec, 1895, she began to be 
troubled with burning during micturition; at the same time 
several " pustules " developed on the outside of the labia majora, 
which burst after several days and healed over. There w T as also 
a painful swelling of the right inguinal glands, lasting several 
weeks and disappearing finally with rest in bed and compresses. 
In Feb., 1896, she was troubled with pain in the throat, and 
for two weeks was unable to swallow solid food. These symp- 
toms improved after gargling with alum. A few days afterward 
an erythematous eruption appeared on the throat, on the flexor 
surface of both elbows, and on both legs. Since the end of 
March the eruption has been brown. On May 23d she came 
under hospital treatment; up to that time she had not con- 
sulted a physician. Last coitus six months ago ; last menstru- 
ation, April 29th. Has never given birth, nor had an abortion. 

Present Condition. — Eroded, edematous papules on both 
large arid small labia, especially on the right side; inguinal 
glands on both sides much enlarged ; at the anus the mark of 
an old papule. On the lower extremities a specific eruption in 
process of regeneration ; intense leukoplasia of the neck ; both 
tonsils enlarged and ulcerated. 

Cured after twenty inunctions. 

Black Plate (PI. 24a) : Front view of the same case. 




Tab. 24. 



■ 



LithJnsi y. K Rhi'IiIioM . Mimchm 



Tab. 24 a, 




PLATE 25. 
Flat, Glistening Papules on the Forehead and Face. 

N. M., 26 years old, locomotive engineer; admitted Oct. 5, 
1896. The forehead presents irregular patches of red and a few 
papules but slightly raised above the level of the skin. There 
is a narrow circle of red at the periphery of the papule ; the 
center shows a brown discoloration, while the epidermis in the 
intermediate zone has a tense and faintly glistening appearance. 
On the alse of the nose and on the chin are similar papules, less 
distinctly marked. 

Other symptoms : a maculopapular Syphilide on the trunk ; 
moist papules on the skin of the scrotum and on the skin of 
the penis ; on the foreskin the scar of a sclerosis. 



PLATE 26. 
Syphilitic Alopecia Areolaris. 

S. H., 25 years old, works in a brush-factory ; admitted April 
13, 1896. In Nov., 1895, patient had a chancre ; in December he 
was treated in the hospital for an eruption. The present symp- 
toms developed three weeks ago. 

Present Condition.— On the forehead and on the hairy 
scalp are numerous pustules, some with the scabs still on 
them. Where a pustule has dried up and shed its scab the 
hair is gone completely, the base of the pustule is converted 
into a glistening scar, and the hair-follicle is not visible. The 
general growth of hair is good, but there are areas where the 
hair is loose, especially about the "bald spot." The rest of 
the body presents, in addition, a large macular Syphilide on 
the trunk and eroded papules about the anus and genitalia. 
The lymph-glands in general are swollen. Additional erup- 
tions of a papulopustular character appeared later on the 
hairy scalp, so that this part of the body is to be regarded as 
the principal seat of the syphilitic eruption. 

Cured by the use of white-precipitate ointment on the head 
and twenty inunctions of 5 g. (3jss) each. 



PLATE 26a. 
Papules on the Hairy Scalp. 

T. A., 33 years old, works in a market. Under treatment 
from May 26 to June 25, 1897. Patient has never had a 
venereal disease. He began to notice his present condition 
two weeks ago. Last coitus four weeks ago. 

Present Condition. — Ulcerated papules on the lower surface 
of the penis and on the scrotum. Multiple swelling of the 
inguinal glands. Raised papules about the anus. Maculo- 
papular Syphilide on the trunk and extremities. Papulopus- 
tular eruption on the head, with alopecia areolaris. Cervical 
and axillary glands enlarged. Palmar and plantar psoriasis. 
The mucous membranes of the mouth and throat are not 
affected. 

Treatment. — White-precipitate ointment. Labarraque's so- 
lution locally. Antiseptic mouth-wash. Cured after twenty- 
five inunctions. 



Tab. 26. 




1 



; 




y 






Tab. 26 a. 





PLATE 27. 
Small Pustules on the Face. 

E. H., 28 years old, hostler ; admitted Feb. 15, 1896. Five weeks 
ago an ulcer formed on the frenum. During the past week 
swelling and suppuration of the inguinal glands on the right 
side. Meanwhile a typical induration developed in the base of 
the ulcer, and on the trunk a scanty papular Syphilide. When 
the inunctions were begun the eruption became more distinct 
and spread to the back, neck, and face. On the face the erup- 
tion takes the form of hard nodules, ranging in size from the 
head of a pin to a pea, and surrounded by a reddish-brown or 
copper-colored halo. The center of the pustule consists of a 
horny core, which can be easily removed, exposing the newly 
formed, glistening epidermis beneath. Some of the nodules 
are collected in groups. 

Cured after twenty-five inunctions. 



Tab. 27. 



# I 







i 9 






ur 





^ 









o 
















LitlLAnsi.v. F. Rpichhold , München 



Tab. 28 a. 




PLATES 28, 28a, 28b. 
Pustular Syphilide. 

P. J., 33 years old ; admitted Dec. 1, 1895. Patient is sick for the 
first time ; had his last coitus two months ago, and first noticed 
the eruption three weeks ago. He often suffered from sore 
throat when he was a child. 

Present Condition. — Both tonsils are enlarged and fissured. 
The left presents a ragged ulcer with shreds of necrotic tissue 
clinging to the surface. The submaxillary glands are as large 
as pigeons' eggs, the middle cervical glands about the size of 
hazelnuts. The axillary glands are also enlarged, but the epi- 
trochlear and inguinal glands are practically normal in size. 
The trunk is covered with an extensive macular Syphilide. In 
the epigastrium are small, lichenoid papules which already show 
a yellow discoloration. Numerous papules and pustules, some 
of which are shedding their scabs, are distributed over the ex- 
tensor surfaces of the upper extremities, and here and there on 
the thorax and back. The pustules are more numerous on the 
back, especially in the sacral region, and on the legs, where they 
are larger and run together to form eczematous pustules cov- 
ered with scabs, especially about the ankles. On the upper ex- 
tremities the pustules are of a light coppery hue at the periph- 
ery ; those on the legs, on the other hand, are livid and of a dark 
coppery red. 

The hairy scalp and the palms of the hands are also the seat 
of a papular eruption. The acneiform pustules on the legs are 
surrounded by extensive inflammatory areas which form an 
almost continuous sheet. Where the process has been going on 
for some time the epidermis is covered with broad, flat crusts, 
and comes off in large sheets wherever the pustules are closely 
crowded together: at first it becomes puckered over the in- 
flamed area, then cracks, and finally loosens and comes off. 
The new epidermis underneath is also inflamed. 

Patient was treated with hypodermatic injections of subli- 
mate, and discharged after five weeks, cured. 

Colored Plate : Part of the eczema-pustules on the left leg, seen 
in the black plate (Plates 28a, 28b). 



ft 



- 



b 



M 






Tab. 28. 









ttr 



LnhAist v. F. ftewhhbld , München 



Tab. 28 b. 




PLATES 29, 29a. 

Proliferating Pustular Ulcers (Frambesia or Yaws) on 
Both Calves. 

K. E., 18 years old; admitted Feb. 21, 1896. Patient was 
under treatment in this hospital last year for gonorrhea of the 
urethra, vagina, and canal of the cervix. A short time after 
she was discharged from the hospital she contracted a sclerosis 
on the left labium minus ; was treated for six weeks and dis- 
charged after all specific symptoms, except general glandular 
enlargement, had disappeared. Until a week ago, the patient 
says, she was quite well. On that day she felt a violent itching 
on both legs; scratching was followed by the appearance of 
pustules, which were later converted into ulcers. 

Present Condition. — On the right leg, below the calf, is a 
node as large as a dollar, composed of several smaller ones : the 
center is occupied by a discolored wound covered with a crust, 
while the periphery is made up of seven separate nodules as large 
as a bean, rising from 2 to 3 mm. above the level of the skin. 
The surface of each nodule is furrowed and, in places, destitute 
of epidermis so as to present fissures, while the remaining 
parts are covered with slightly adherent crusts of dried epider- 
mis. The periphery of the entire node is slightly inflamed, 
and t like all parts of the node itself, painful on pressure. 
Above the large node is a fresh pustule. A similar sore, only 
much greater in extent, is found on the left leg (see PL 29a), 
There is typical swelling of the inguinal glands, but they are 
not painful. The axillary and cervical glands are also enlarged. 
The genitalia are flabby. Gonorrhea of the urethra and vagina. 
The patient says that the ulcers on the legs are painful, espe- 
cially at night. 

Treatment. — Inunctions. Compresses of aluminum acetate 
solution. 



Tab. 29. 




Ditktasi v. F Reiclihold, Mrinclißn 



Tab. 29 a. 



PLATE 30. 
Psoriasis Syphilitica Plantaris. 

R. P., 24 years old, cashier ; admitted June 18, 1896. First 
attack. The eruption appeared five days ago. No history of 
a previous disease or its duration could be obtained. 

Present Condition. — Numerous papules, varying in size 
from the head of a pin to a pea, are developing on the soles, 
especially in the hollow of the foot. Their peculiar reddish- 
brown discoloration and hard consistency indicate a horny 
change of the thick plantar epidermis. Numerous follicular 
papules are seen on both labia majora, at the commissure, and 
about the anus. General glandular enlargement. Pale, papu- 
lar Syphilide on the trunk. 

Treatment. — Labarraque's solution locally. Antiseptic 
mouth-wash. Inunctions of 5 g. (3jss) ung. hydrarg. 

Course. — After twenty inunctions all syphilitic symptoms 
disappeared. Patient was discharged July 11th, cured. 






Tab. 30. 




• 



\ 



Liihinsi.v. F. Reichhold . Münclv 



PLATE 31a. 
Eroded Papules between the Toes. 

T. J., 20 years old, servant-girl; admitted Nov. 25, 1896. 
The patient says this is the first time she is sick, and that she 
noticed the disease in the genitalia for the first time five weeks 
ago. 

Present Condition. — Flat, macerated, coalescing papules on 
the inner surfaces of the third, fourth, and fifth toes. The toes 
themselves are swollen and inflamed. On the soles of both 
feet, papules covered with horny epidermis (psoriasis). At the 
edges of the labia majora and about the anus raised papules, 
some of which have run together. Figurate, macular Syphilide 
on the trunk. Inguinal and cervical glands enlarged. Both 
tonsils are swollen and, together with the surrounding palato- 
glossal arches, inflamed and covered with eroded papules. 

Treatment. — Sublimate baths for the feet. Applications of 
5 per cent, white-precipitate ointment. Baths. Antiseptic 
mouth-wash. Inunctions. Cured in thirty days. 



PLATE 31b. 
Papules and Fissures between the Toes. 

P. B., 27 years old, charwoman, married; admitted Nov. 19, 
1895. The patient says she first noticed her present disease 
three months ago. At that time she became aware of a moist 
spot between the fourth and fifth toes, which she took for a 
corn. The other ulcers developed gradually ; there was a good 
deal of tissue-destruction, and for the past month walking has 
been attended with great pain. The inflammation surrounding 
the ulcers has been increasing during the past three weeks ; 
the ulcers themselves have become deeper. 

Present Condition. — Degenerating papules between the 
first and second toes, presenting much suppuration and necro- 
sis, with a hemorrhagic scab in the center. Between the fourth 
and fifth toes, which are also swollen, similar degenerating 
papules are seen. All the anterior portion of the foot is swollen 
and inflamed. The labia majora are edematous and covered 
with coalescing papules; on the labia minora and about the 
anus are isolated eroded papules. 

Treatment. — Labarraque's solution (toes and genitals). 
Baths. White-precipitate ointment (toes). Inunctions. Cured 
in twenty-seven days, 



Tab 31 




- 





LitkAnst v. Y Reiohlmld , Mow 



PLATE 32. 
Syphilitic Paronychia of Both Hands. 

B. J., 50 years old, laborer ; admitted Oct. 5, 1896. The patient 
has been suffering from syphilis for the past twenty-one months, 
and was treated in the hospital a year ago. His present attack 
began a month ago. 

Present Condition. — The disease has attacked the follow- 
ing parts with varying intensity : thumb, index and middle 
fingers of the right hand ; index, middle, and ring fingers of 
the left hand ; big toe of the left foot. Where the disease is 
mild the fingers show merely a swelling and redness of the 
distal phalanges and slight ulceration at the margin of the nail. 
Those which are more severely attacked, as the index of the 
right and the middle and ring fingers of the left hand, are very 
red, and the distal phalanx, especially the margin of the nail, 
swollen to the finger-tip ; the nails are turned in and separated 
from their matrix. The latter is converted, at the margin and 
under the nail, into a granulating, suppurative ulcer. Papules 
on the buccal mucous membrane, about the anus, on the 
scrotum, and on both forearms. The patient complains of con- 
stant burning-pains in the tips of his fingers, which he carefully 
guards against injury. 

Treatment. — Sublimate baths for the hands. Inunctions. 
Cured after twenty-five inunctions. The nails are discolored a 
brownish-black, brittle, and turned in at the edges. 



CM 

TO 







PLATE 33. 
Proliferating, Eroded Papules of Diphtheritic Character. 

J. M., 27 years old, coachman; admitted June 12, 1897. 
Patient has never had a venereal disease. Noticed his present 
trouble four weeks ago. Last coitus three months ago. 

Present Condition. — Diphtheritic papules on the glans 
penis, at the edge and on the inner surface of the prepuce, on 
the skin of the penis, and on the scrotum. Proliferating 
papules on the perineum, on both thighs, and on the buttocks. 
Desquamating papules on the palms of both hands and the 
soles of both feet. Raised papules, of a livid color, covered 
with crusts, on the skin of the abdomen. Inguinal, axillary, 
and epitrochlear glands swollen. 

Cured after ten inunctions and ten injections of 1 per cent, 
sublimate solution. 





m rv 





PLATE 34. 
Proliferating Papules. 

T. A., 17 years old, servant-girl ; admitted July 2, 1897. First 
venereal attack. Patient first noticed the condition of the 
genitals two weeks ago. Last coitus three weeks ago. 

Present Condition. — At the edges of the labia majora, on 
the perineum, and about the anus proliferating, raised papules, 
some of which present necrotic decay and suppuration in the 
center. 

Inguinal glands swollen and hard on both sides. The os 
displaced to the left, intact. 

Cured after twenty inunctions. 



PLATE 35. 

Proliferating Papules on the Labia Majora, in the Genito= 
crural Fold, and on the Perineum as far as the Anus. 

S. M., 24 years old, seamstress; admitted May 15, 1896. 
Proliferating, rapidly growing, inflammatory papules at the 
edges of the labia majora and in the anal folds; similar but 
smaller ones on the buttocks and the inner surfaces of the 
thighs. The papules are moist, but only a few present signs of 
degeneration and suppuration, so that this form is characterized 
chiefly by its inflammatory nature and rapidity of growth. 

In addition, the patient is suffering from a vaginal discharge ; 
the inguinal glands are swollen, and the mucous membrane of 
the isthmus of the fauces is diseased. 

Treatment. — Labarraque's solution locally. Inunctions. 



Tab. 35. 




J 



V 



München 



PLATE 36. 

Proliferating Papules on the Labia Majora, on the Peri= 

neum, and about the Anus. 

G. A., 20 years old; admitted Dec. 19, 1896. Patient says 
she has been ill for two weeks. 

Present Condition. — Kaised papules, eroded at the surface, 
some isolated, others coalescent, on both labia majora, and 
extending downward over the perineum to the anus. In 
places the proliferations are raised as much as \ cm. above the 
surrounding level, and of a hard though elastic consistence. 
Inguinal glands much enlarged, the remaining glands of the 
body only moderately so. Leukoplasia of the neck. 

Cured by local application of Labarraque's solution and 
inunctions (twenty). 



PLATE 37. 
Hypertrophic Papules and Folds about the Anus. 

J. T., 22 years old, laborer ; admitted July 18, 1897. Patient 
has been treated twice for papules on the genitalia and has had 
altogether thirty-seven inunctions. Noticed the present trouble 
three weeks ago. Says he had his last coitus in Sept., 1896. 

Present Condition. — Numerous livid, infiltrated folds about 
the anus. Close to these large, dry syphilitic proliferations, of 
about the size of a walnut, hard, irregularly wrinkled. In the 
anal fold and on the buttocks are also smaller, moist papules on 
a level with the skin. 

The patient looks very much neglected, is covered with a 
tertiary macular Syphilide, the glands of the body are swollen, 
and the mucous membrane of the throat is diseased. 

Cured by thirty inunctions. 









. 






Tab. 37. 







^ 






rhhoiil . Mim. Im 



PLATE 38. 

Old Annular Papules that have begun to Heal in the 
Center. 

T. B., 17 years old, servant-girl; admitted July 29, 1897. 
Patient says she was treated a year ago in the hospital for 
a disease of the genitals which she is unable to describe in 
detail. Her present attack began two months ago. 

Present Condition. — The labia majora, with their prolonga- 
tions as far as the anus, and both groins are thickly covered 
with partly isolated and partly coalescent papules. Here and 
there, owing to regeneration of the central portion, the patches 
are converted into circular wreaths as large as a penny, raised 
above the level of the skin, with a dark-brown pigmentation 
in the center: or the inner margin of the wreath is degen- 
erated at the surface, while the center is covered with whitish- 
gray scar-tissue. The inguinal glands are swollen. On the 
front of the legs and on the back and buttocks are seen a 
number of flat, pigmented spots as large as peas. In the 
right supraclavicular region is a light-brown pigmented area 
about as large as a dollar, with here and there, about the 
periphery, a few slight papular elevations. Cervical glands 
moderately swollen. Leukoplasia of the neck. Mucous mem- 
brane of the mouth intact. 

Treatment. — Antiseptic mouth -wash. Baths. Inunctions. 
After twenty-five inunctions the circular groups of papules are 
seen to be converted into dark, reddish-brown, pigmented areas 
corresponding in distribution to the specific eruption. Inguinal 
glands shrunken. 



$ 





r^h. 



TD Q 





5 



PLATE 39. 

Diphtheritic Papules on the Mucous Membrane of the Os 
Uteri and Vagina. 

M. A., 50 years old, charwoman. 

The os presents fissures and contracted scars, the result of 
former parturitions. A number of discolored ulcers, sur- 
rounded by inflammatory tissue, are seen ; two on the anterior, 
one on the posterior lip, and several, partly coalescent, on the 
posterior wall of the vagina. The patient is not aware of the 
ulcers in the vagina and os uteri. 

Isolated, moist papules are seen on the labia, in both inguinal 
regions, on the perineum, and on the inner surfaces of both 
thighs. On the trunk and neck a pustular Syphilide, mingled 
with papules. The inguinal as well as all the other glands of 
the body are enlarged. 

Patient has passed the climacteric ; she says she has noticed a 
discharge and the " ulcers " for the last two weeks. She has 
given birth to seven children, the last one eighteen years ago. 

Sublimate was applied locally to the genitals, and the patient 
was subjected to nine inunctions and twenty injections, as a 
general treatment. After being under treatment eighty-seven 
days she was discharged cured. 

This case dates back to the time when the author was assist- 
ant in Siegmund's clinic, 1879-80. 



Tab. 39. 







PLATE 40. 

Diphtheritic Papules on the Mucous Membrane of the 
Upper Lip and Left Side of the Mouth. 

T~. A., 33 years old, tanner; admitted Nov. 12, 1896. The 
patient was treated a year ago for syphilis. The ulcers on the 
scrotum and in the mouth made their appearance four weeks 

ago- 
Present Condition. — In the mucous membrane of the 
upper lip and of the cheek near the left angle of the mouth, 
and on the tonsils, are several discolored papules, with deep, 
ulcerated centers. Remnants of papules on the palms of the 
hands. Partly healed papules on the penis, scrotum, and 
buttocks. On the trunk and extremities brown pigmented 
papules in process of regeneration. General glandular enlarge- 
ment. 

Treatment. — Sublimate mouth -wash. Labarraque's solu- 
tion externally. Cured after twenty-five inunctions. 



Tab. 40. 




ichhoM , München . 



PLATE 41a. 

Infiltration and Superficial Necrosis of the Mucosa and 
Sub mucosa of the Upper Lip. 

K. T., 70 years old, workman in a gas-factory; admitted Aug. 
11, 1896. Patient noticed the swelling on the upper lip for the 
first time in May of last year. He says he was never sick 
before ; denies syphilitic infection. 

Present Condition. — About the middle of the upper lip an 
elliptical infiltration about as large as a half dollar, the long 
axis corresponding with that of the lip. At the left extremity 
a fissure about 5 mm. wide and J cm. long. The submaxillary 
glands can be felt on both sides, but not the parotid lymphatic 
glands. The lymph-glands of the rest of the body but little 
affected. 

Treatment. — Inunction. Cured after twenty applications. 



PLATE 41b. 

Ulcerating Papules and Incipient Leukoplasia of the 
Tongue. 

P. P., 49 years old. Has been treated as an out-patient. The 
patient says that four years ago she noticed fiery-red, isolated 
nodules on the tongue for the first time. Various remedies 
were tried, among them cauterization (with lunar caustic), 
which caused the nodules to disappear for a time, but they 
always recurred. A year ago they again appeared, and the 
patient underwent twenty inunctions, whereupon the eruption 
subsided. Two months ago the nodules began to develop 
again, and with them whitish, coalescent ulcers. 

Present Condition. — The tongue is only slightly swollen; 
at the back the papilla? are still intact ; the front is smooth and 
covered for the most part with a cloudy, whitish layer of epi- 
thelium. A discolored, slightly raised ulcer extends across the 
tongue and along both margins, while a similar ulcer, as large 
as a pea, occupies the tip of the tongue a little to the left of the 
center. The ulcers are slightly raised above the surface and 
surrounded by a sharply defined inflammatory border. 

The submaxillary glands are hard and moderately swollen. 
Painful mastication. 

After the patient had been treated for eight days, scar-forma- 
tion began in the middle of the ulcer, which was finally con- 
verted into a whitish, epithelial hyperplasia. 



Tab. 41. 





München 



PLATE 42a. 
Elevated, Coalescent Papules on the Hard Palate. 

E. S., 21 years old, prostitute ; admitted Nov. 16, 1896. The 
patient was first infected in 1893, and has since been treated 
nine times for syphilis. Most of the relapses consisted in papu- 
lar eruptions on the genitals. The present attack first attracted 
the patient's notice two weeks ago. 

On the hard palate, stretching from the fossa behind the in- 
cisors to the soft palate, is a coalescent group of mulberry-like 
proliferations of hard, yet elastic consistence, somewhat lighter 
in color than the slightly inflamed mucous membrane of the 
surrounding parts. The edges of the soft palate and uvula are 
slightly thickened and distorted as the result of a former attack 
of the disease, which even now betrays itself by an infiltration 
on the edge of the soft palate and uvula. The vibrations of 
the pillars of the fauces during phonation are sluggish and 
irregular. Concomitant symptoms are found in flat, glistening 
papules, as large as a bean, on the labia majora, and in a gen- 
eral glandular enlargement. 

Treatment. — Inunctions. The specific infiltrations disap- 
peared, the proliferations on the hard palate subsided, and the 
mobility of the pillars became almost normal. 



PLATE 42b. 
Leukoplasia (Psoriasis) Lingua?. 

C. J., 49 years old. Under treatment for emphysema and 
pulmonary catarrh in Ward No. 12. 

The patient has had various diseases. In 1872 or 1873 he 
acquired a hard chancre, which was followed by eruptions on 
the skin and sores in the mouth. With the exception of local 
remedies and river-baths the patient did not undergo any treat- 
ment for his disease. Lunar caustic, gargles, and precipitate 
ointments were the local remedies he employed. 

The patient used to be a heavy smoker; when he worked 
on a freight train he used to smoke both cigars and pipe 
day and night. In 1891 he noticed for the first time whitish 



Tab. 42. 





LitkAnsi v. \\ Reichhoi'i. Mimrhm 



vesicles on the tongue, which bled when they were opened 
with a pin. The present condition of the tongue the patient 
says he has noticed for the last eighteen months. He is thin, 
but not cachectic. 

Present Condition. — The tongue is not perceptibly swollen ; 
but the patient can only protrude it a little and with difficulty. 
The surface is white, moderately thickened, and divided into 
irregular islands by shallow grooves. These grooves do not 
appear to be due to contracting scars, but rather to correspond 
to the normal furrows in the tongue. On the other hand, the 
islands appear slightly raised, owing to the thickening of the 
epithelium and the moderate inflammation which preceded 
their formation, and which the patient described as blisters. 
The tongue does not feel hard, and in its present condition is 
not painful. All delicate tactile sensibility is lost. 

The chewing of highly seasoned food or sharp pieces of 
bread is apt to produce fissures, which, however, heal of their 
own accord in a few days. The epithelium of the buccal 
mucous membrane opposite the alveolar border is also some- 
what cloudy, but not as thick as that of the tongue. 

Submaxillary glands are not swollen. No demonstrable 
syphilitic symptoms. 



PLATE 43a. 
Condylomatous Iritis. 

L. P., 23 years old, footman; admitted Nov. 30, 1896. The 
patient complains of pains in the right temporal region, and 
tearing pains in the right eye for the past five days. The lids 
of the diseased eye were adherent; lachrymal secretion very 
abundant. Syphilis denied. 

Present Condition. — Ciliary congestion of the right eye. 
Cornea and aqueous chamber normal ; pupil dilates in the form 
of a kidney upon application of atropin, owing to a sharp 
synechia at the external inferior portion. From the inferior 
pole of the external quadrant a reddish tumor as large as 
a hemp-seed projects into the pupil. On the raphe of the 
penis, about the middle of the pendulous portion, is a moder- 
ately infiltrated, pigmented scar of a livid coppery hue, about 
as large as a bean. Multiple, indolent swelling of inguinal, 
axillary, and cervical glands. The trunk is covered with a 
diffuse Syphilide consisting of small pustules. 

Palms of the hands, soles of the feet, and buccal mucous 
membrane intact. 

Subconjunctival injections of sublimate. Inunctions. Cured. 



PLATE 43b. 
Gummatous Tarsitis of the Left Eye. Trachoma. 

E. H., 24 years old ; admitted Nov. 14, 1895. The woman has 
been suffering from trachoma for several years. Three years 
ago she contracted syphilis and had a rash on the entire body, 
for which she underwent an inunction cure. For the past week 
she has felt a tumor under the left upper eyelid. 

Present Condition. — The patient is pale and delicately built ; 
lymph-glands generally are enlarged. Front and back of the 
neck covered by a typical leukoplakia. Both tonsils are enlarged 
and fissured. 

Condition of left eye : the conjunctiva of the lower lid 
presents various alterations due to trachoma. A tumor about 
as large as an almond can be felt through the upper lid. 
Tarsal conjunctiva velvety and deeply injected. The con- 
junctiva over the convex border of the tarsus and the inter- 
mediate portion is converted into a brawny wheal, which 
merges internally into the slightly infiltrated semilunar fold. 
About the center of the wheal is a shallow ulcer, about as large 
as a pea, with grayish-white, discolored floor and indurated 
margin. 

Treatment. — Inunctions. Potassium iodid internally. Cured 
after thirty inunctions. 



Tab. 43. 




iuä 





Litfrutotf v. F. ReirlihoW . München 



PLATE 44, 44a, 45. 
Syphilitic Frambesia (Yaws). Syphilis Praecox. 

J. P., 25 years old, prostitute; admitted April 6, 1896. In 
April, 1895, the patient was treated for a soft chancre on the 
genitals. In October, 1895, she acquired a hard chancre on 
the right labium majus; a short time afterward an eruption 
appeared. The patient was subjected to thirty-five inunctions. 
Present attack began four weeks ago. 

Present Condition. — On the hairy scalp (Plates 44, 44a, 
45) are several papillomatous, warty excrescences as large as 
a half dollar, covered with scales and crusts. Serpiginous 
ulcerations on the cartilage and left ala of the nose, on the 
right upper arm, below the left mamma, and on the back ; 
here and there on the trunk a few papular infiltrations. 

Fig. 45 represents the same case : Mulberry-like proliferations 
on the hairy scalp after the crusts have fallen off. 



J2 




Tab. 44 a. 




to 



ee 




PLATES 46, 46a, 47. 

Gummatous Ulcers on the Labia Majora, the Posterior 
Commissure, the Right Labium Minus, and the Vagina. 

W. A., 26 years old, servant-girl; admitted June 15, 1896. 
She has been syphilitic since 1890, and is now undergoing treat- 
ment for the third time in this hospital ; the first attack occurred 
in 1890, the second in the latter part of 1892. The present at- 
tack began only a few weeks ago, so that the patient has been 
free from any noticeable syphilitic symptoms forthree and ahalf 
years. 

Both labia majora, the clitoris, and the labia minora are 
hypertrophied ; their consistence not perceptibly increased. 
At the margin of the left labium majus are three circular 
ulcers as large as a bean; at the margin of the right (Plates 
46, 46a), two about twice as large, and on the posterior com- 
missure two still larger ones, separated by a narrow bridge of 
tissue. These ulcers have sharply defined edges; the base is 
irregularly degenerated, and they are for the most part covered 
with pus. Similar, smaller ulcers, to the number of about 
eleven are found on the external surface of the right labium 
minus, in the vestibule, and about the middle of the vaginal 
canal. They have the same degenerated base, but are neither 
as large nor as deep as the others (PI. 47). 

At the right angle of the os is a discolored ulcer, larger than 
a bean. The inguinal glands on both sides are palpable and 
spindle-shaped. Pigmented scars on the legs, and here and 
there on the trunk. 

Treatment. — The ulcers were sprinkled with iodoform pow- 
der. Twenty-four grains of potassium iodid per diem. After 
a month most of the ulcers had healed. The labia were still 
enlarged. The patient had improved a good deal, and an 
inunction treatment was ordered. Cured after twenty inunc- 
tions. 



Tab. 46. 







II 



Tab. 47. 




I.itli Ana v. F KeichhnM München 



PLATE 48a. 
Gummatous Ulcer of the Left Nipple. 

H. R., 26 years old, drummer; admitted Oct. 9, 1896. Pa- 
tient has been suffering from syphilis for six months» and has 
been almost constantly under mercurial treatment during that 
time ; in spite of that, however, the entire body became covered 
with ulcers, to the number of seventy-four. He is also suffer- 
ing from an affection of the left elbow-joint. 

Present Condition. — The left nipple is replaced by an 
ulcerating sore; the areola is swollen and converted into a 
deep infiltration. On the hairy scalp are several pustular sores 
covered with crusts. In the right nostril a fissure, with infiltra- 
tion of the base and ala of the nose. On the root of the penis 
a broad scar from the sclerosis. Numerous partly healed sores 
and pigmented and desquamating scars, the remains of the 
above-mentioned sores, are scattered over the entire body. The 
patient is emaciated and anemic; he complains of lassitude 
and headache. 

Treatment. — Decoctum Zittmann. 1 Inunctions. 

1 Decoctum sarsaparillse compositum (sarsaparilla, senna, glycyrrhiza, 
fennel and anise, with calomel, cinnabar, and alum). 



PLATE 48b. 
Gumma of the Breast. 

C. R., 41 years old, charwoman ; admitted May 28, 1897. For 
the past year the patient has noticed a tumor in the left 
breast, which gradually grew larger and began to ulcerate last 
fall. She says she has always been well otherwise. She has 
borne four living children ; has never nursed ; never had an 
abortion. 

Present Condition. — In the outer half of the left mammary 
gland are a number of old and recent scars, which palpation 
shows to be due to infiltrated bands of tissue, radiating over 
the gland almost as far as the left margin. About the anus, on 
the perineum, and on the posterior surface of the labia major» 
the marks of old papules, surrounded by a red halo. Multiple 
swelling of the inguinal glands on both sides, and also of the 
epitrochlear and axillary glands. Mouth and throat intact. 

Treatment. — Potassium iodid, 24 grains per diem. Gray 
plaster. 



Tab. 48. 



mm 





•uit.Ajisi Miinrhm 



PLATE 49. 
Syphilitic Rupia. 

K. M., 46 years old, waiter's wife ; admitted June 12, 1896. 
With the exception of varicella in her twenty-second year, the 
patient says she has never had any disease. 

Five or six years ago the patient suffered from violent head- 
ache ; two years ago she had an ulcer on her leg. Patient had 
borne twice, in her twenty-fourth and in her twenty-seventh 
year (out of wedlock) ; the children lived for some time ; no 
abortion. Venereal disease denied. Patient is a heavy 
drinker. 

Ulcers first appeared on the arms four months ago. 

Present Condition.— Patient is very much emaciated. On 
the left arm, above the elbow, an oval group of infiltrations, 
covered for the most part with rupia-like scabs. The scars are 
only skin-deep. About the periphery, especially at the upper 
part, some desquamation of the epidermis. 

In two places recent, superficial infiltrations are seen, over 
which the skin is raised, forming two cloudy blisters. 

On the right arm, extending below the elbow, a semicircular 
group of similar sores, some of them already converted into 
scars, some still covered with rupia-like scabs, and some quite 
recent, resembling blisters. General glandular enlargement. 

Whitish scars are seen in the left groin and at the edge of 
both labia majora. 

Internal organs normal, with the exception of an old process 
at the apex of the right lung. 

After the scabs had fallen off, round and oval ulcers appeared 
in the affected areas, penetrating the skin and covered with 
pus. 

Scar-tissue began to form after the ulcers had been treated 
with red-precipitate ointment for two weeks, and iodid of iron 
had been given internally. With the exception of a slight red- 
ness at the site of the ulcers nothing abnormal in the skin. 



Tab. 49. 




LithAiiM v. Y Reiohhold. München 



PLATES 50, 50a. 
Serpiginous, Gummy Ulcers. 

F. P., 28 years old; admitted Feb. 10, 1896. The patient 
became infected with syphilis in her eighteenth year, and was 
at that time treated with inunctions. She had no relapses 
until fifteen months ago, when a tumor began to make its 
appearance in the lateral cervical region, and was followed by 
tumors in other parts of the body, all of which softened and 
broke down. The ulcerations were cured by inunctions, leav- 
ing scars. 

The ulcers now seen on the right thigh and on the left leg 
developed six weeks ago. 

Present Condition. — There are no alterations in the genitals 
at the present time. The glands in general are enlarged. On 
the trunk and extremities are seen numerous scars of varying 
size, some pigmented, some white, which, from their shape, 
evidently represent the remains of serpiginous ulcerations. 
Here and there, especially in the mammary region, along the 
costal margin, over the head of the right humerus, on the 
flexor and extensor surfaces of the left upper arm, on both 
sides of the neck, and over the e} r ebrows localized eruptions 
are seen. The papules are livid red, distinctly raised above the 
level of the skin ; the edges are everted and covered with sev- 
eral superjacent, dirty brown scabs, some of which, especially 
on the left arm, attain the size of a penny (see Plate). The 
center is occupied by white and brown scars ; as they approach 
the periphery the color changes to a reddish hue, the scars 
become puckered, and finally merge into a raised zone of infil- 
tration. This infiltrated margin is composed of single nodules, 
closely crowded together and merging into one another. A 
few of the nodules are covered with very thin crusts and scales ; 
the older ones, on the other hand, are covered with several 
layers of crusts. On the lower third of the left leg is a sharply 
circumscribed ulcer, about as large as a penny, with discolored 
floor. On the inner margin of the right thigh, above the knee, 
another similar ulcer. 

The mucous membrane of mouth and throat is intact. 

Treatment.- — Local application of white-precipitate oint- 
ment; inunctions of ^jss ung. einer. The skin-lesions disap- 
peared rapidly. Patient was discharged before the end of the 
cure, at her urgent request. 



Tab. 50. 







Lull An si v. Y Reirhholil . München 



Tab. 50 a. 




PLATE 51. 
Serpiginous, Gummy Ulcers of the Right Calf. 

P. T., 30 years old ; admitted April 20, 1896. Four years ago 
the patient contracted a disease from her husband, who was then 
suffering from an eruption. The disease began in the left ton- 
sil. The cervical glands became swollen ; later she was troubled 
with an eruption and with headache. Since that time the 
patient was several times treated for various manifestations of 
the disease, but never continuously. Eleven months ago she 
began to notice nodes on the calf of the left leg, which soon 
ulcerated. She has had seven children ; the last one was born 
at term, but she says it is afflicted with an eruption. 

Present Condition, — On the calf of the right leg is a group of 
typical, serpiginous, gummy infiltrations and ulcers, surround- 
ing a central scar, the remains of old ulcers ; about the periph- 
ery circular and elliptical ulcers of varying size, with fairly 
well-defined edges and the base covered with granulations and 
detritus. Similar ulcers are seen above the left knee. In the 
right groin and on the right labium majus the remains of infil- 
trations and the scars of papules can still be seen. Some slight 
pigmentation can be made out on the trunk and extremities. 
The inguinal glands are only slightly, the cervical glands typic- 
ally enlarged. 

A cure was effected by local applications of red-precipitate 
ointment, internal administration of potassium iodid, and a 
course of twenty-one inunctions. 



Tab. 51. 




I 




LiTti.An.-ci v. F Reichhold . München 



PLATE 52. 

Cutaneous Gumma on the Dorsum of the Foot. Gumma of 
the Pharynx. 

B. M., 37 years old, married ; admitted Dec. 19, 1895. Said 
to have had a nasal voice ever since her eighth year. Nothing 
in the history has any special bearing on the origin of the dis- 
ease. The patient has had six children, all of whom died in 
infancy from intercurrent diseases. 

Present Condition. — The soft palate and uvula are entirely 
wanting, so that the nasopharyngeal cavity extends high up 
into the roof of the mouth. The posterior wall of the pharynx 
presents a yellowish, discolored, ulcerated area about as large 
as a penny. 

On the dorsum of the right foot, corresponding in position to 
the fourth and fifth metatarsophalangeal articulations, is an 
ulcer as large as a dollar, filled with proliferating granulations. 
The edges, where the} 7 exist, are sharply defined and over- 
hang the mass of granulations, so that a probe can be inserted 
2 to 4 mm. under the undermined edges. The ulceration ex- 
tends down to the sheaths of the tendons, although the mova- 
bility of the toes is unimpaired. 

The case was treated surgically. 



PLATE 52a. 
Ulcerative Gummata of the Pericranium. 

K. E., 50 years old, pauper. The patient has been treated 
repeatedly in a ward during the last three years for severe 
syphilitic manifestations. 

On the right parietal bone is a depression as large as a dollar, 
at the bottom of which the bone is exposed. The soft parts 
about the periphery of the ulcer-sore are loosened. On the 
right frontal bone is a similar, smaller swelling about as large 
as a penny, and a third one is seen on the occiput. There 
also a periosteal gumma on the right tibia. The patient is 
very weak and emaciated, and has edema in the lower ex- 
tremities. 



Tab. 52. 




München 



By careful local treatment and general tonics the gummata 
were gradually absorbed after four months' treatment. The 
one on the forehead healed in such a manner that the integu- 
ment united and the bone was covered by granulation- and 
scar-tissue. 



Tab. 52 a. 




PLATE 53. 

Gumma in the Glands of the Neck, with Destruction of 

the Integument. 

B. K., 32 years old, servant-girl; admitted Oct. 5, 1895. 
There is no history of hereditary disease. Patient says she 
occasionally suffers from nocturnal headache. Two^ years ago 
she was treated in a throat clinic, and a year ago in a surgical 
clinic for an ulcer on one of the lower extremities. Has never 
been subjected to a general antisyphilitic treatment and denies 
any knowledge of the disease. 

Present Condition. — The patient is well nourished, some- 
what pale. Internal organs normal ; has never been pregnant ; 
menstruation regular. 

No alterations can be made out on the external labia or in 
the rest of the genitals. The skin of the neck and throat is 
the seat of a typical leukoplasia. On the external surface of 
the left calf a circular, depressed atrophic scar ; above the left 
external malleolus a scar measuring about 2 square cm., adher- 
ent to the bone, with irregular, circular, and elliptical margin. 
The soft palate and uvula partly destroyed and disfigured by 
scars. 

The inguinal glands are hard, and present a multiple swell- 
ing ; the axillary glands on both sides are even more distinctly 
enlarged, those above the bend of the elbow only slightly so. 

All the glands in the neck, especially those in the left- sub- 
maxillary and supraclavicular regions, are swollen to the size 
of pigeons' eggs and hard and resistant to the touch. Two 
elliptical ulcers about 1 cm. long, corresponding to a submaxil- 
lary and a supraclavicular gland, are seen on the left side of the 
neck ; the ulcers have broken through the skin ; the edges are 
steep ; the floor of the upper one is covered with necrotic tis- 
sue, that of the lower one with yellowish-white pus. Over the 
other swollen glands the skin is loose and freely movable. 

The patient received 24 grains of potassium iodid per diem ; 
the sores were dressed first with iodoform and later with gray 
plaster. The ulcers healed and the glands were reduced in size, 
so that the patient was discharged cured after thirty-eight days, 
the neck having regained its normal outline. 



Tab. 53. 





j 



r\ 



München 



PLATES 54, 54a. 
Gummatous Ulcers of the Skin and Inguinal Glands. 

W. K., 46 years old, tailor ; admitted Jan. 21, 1895 ; died Jan. 
7, 1896. In 1892 the patient had an eruption covering almost 
the entire body, most abundant on the trunk, for which he 
used a white ointment. The nature of the disease was not 
known to him. 

Present Condition. — Pigmented and atrophic cutaneous 
scars can be seen on the entire body, due to the above-men- 
tioned eruption. On the inner aspect of the left thigh are five 
ulcers ranging in size from a penny to a half dollar, penetrat- 
ing below the skin, the base presenting some granulation and 
much purulent necrotic tissue. 

In the groin is a large, oval wound, corresponding to a 
broken-down superficial gland. The other lymphatic glands 
are hard, but little enlarged. The patient is pale and emaci- 
ated ; he keeps the lower extremity flexed at the hip and at the 
knee. The joints themselves are unaffected. His psychical 
condition is normal; his intelligence, however, is of a low 
order. The gummatous ulcers were not affected by potassium 
iodid and local treatment with iodoform, so that inunctions 
were ordered. 

Mar. 21f.. After thirty inunctions the wounds showed active 
granulation and a border of scar-tissue, but the inunctions had 
to be discontinued on account of severe gingivitis and abnormal 
proliferation of the epithelium at the margin of the tongue 
and in the mucous membrane of the cheek, opposite the alve- 
olar border. In spite of careful nursing neither the ulcers 
themselves nor the general condition of the pale, torpid patient 
improved, so that at the end of September the wounds were 
but little reduced in size. 

In the beginning of October a gland in the right inguinal 
region became swollen. The integument became inflamed and 
ulcerated, and a thin, bloody secretion was discharged. After 
three weeks the wound improved somewhat, so that only a part 
of the degenerated gland and a slight granulation could be 
seen in the floor (colored plate). 

Od. 21. Erysipelas developed from the right inguinal fold 
to the middle of the thigh ; incipient bed-sore in the right 
sacral region. 

The erysipelatous inflammation subsided upon the applica- 
tion of compresses of aluminum acetate solution and with 
proper care as to diet and change of position in bed ; but on 
Oct. 24th the patient still complains of severe pain in the right 



as 
H 




hip, which is found to be red and inflamed. This condition is 
also relieved in six days with sodium salicylate internally and 
cold compresses. 

Ophthalmoscopic Examination. — Discoloration of the 
pupil, incipient atrophy. 

The patient complains of severe pruritus. Urine contains no 
sugar, and only small quantities of albumin. The sediment 
contains many leukocytes and bladder-epithelium, but no 
renal elements. 

Bronchitis affecting the larger bronchi of the entire lung. 
The fever is moderate ; in the morning it falls almost to normal, 
in the evening it rises to 38.5° C. The patient gradually sinks 
into a very low state, and has to be roused to take nourish- 
ment ; he barely understands what is said to him and immedi- 
ately relapses into a stupid state. He died Jan. 7, 1896. 

Autopsy. — Body small, very much emaciated. In the left 
inguinal region the skin is destroyed over an area as large as 
the hand. 

In the right groin a similar ulceration, about as large as a 
dollar ; on the posterior aspect of the left thigh is a larger scar, 
freely movable over the muscle ; a smaller one on the external 
surface of the left thigh and over the head of the fibula. 

The skull is thin, very prominent in the suboccipital region. 
The dura mater and soft layers of the meninges present noth- 
ing abnormal. The surface of the brain is somewhat flattened. 
The cortex slightly narrowed. Brain-substance edematous. 
Nothing abnormal in the vessels at the base. 

Both lungs emphysematous ; atrophied (poor in substance) ; no 
adhesions. The bronchi of the lower lobes contain a purulent 
secretion. 

Heart small and contracted ; subpericardial layer presents 
some fatty yellow and red discolorations. Myocardium yellow- 
ish-brown. Valves and vessels present no alterations. 

Liver rather small, convexity increased. The individual 
lobules over the entire surface are very prominent, their fatty, 
yellow color contrasting with the reddish hue of the interven- 
ing connective tissue. The same picture is presented in cross- 
section. On the right lobe is a yellowish, calcified nodule 
about as large as a pea. 

Spleen enlarged and flaccid, stroma increased ; a slight waxy 
luster is seen on section. 

Both Lid ii< ijs much enlarged, tough, the capsule easily re- 
moved. The surface has a waxy appearance ; on section a few 
fine hemorrhagic points are seen; the cortex is increased in 
width, pale yellow, in marked contrast with the flesh-colored 
pyramids, and looks distinctly like bacon. Pelvis dilated and 
filled with fluid containing dark, turbid flakes; the mucous 
membrane discolored by numerous hemorrhages. 



The bladder dilated to its utmost, containing clear urine. 
Mucous membrane strongly injected in places. 

On the right side of the neck of the penis an atrophic scar. 

The mucous membrane of the intestine about the anus is 
puckered and thickened, and protrudes from the anus. 

Over the sacrum a large, irregular ulcer extending chiefly 
toward the right side. 

Diagnosis. — Inveterate syphilis. Cirrhosis of the liver in 
process of regeneration. Amyloid disease of kidneys and 
spleen. Atrophy of the heart. Slight atrophy of the brain. 
General anemia and marasmus. 



Tab. 54 a. 




PLATE 55. 
Gummatous Disease and Necrosis of the Soft Parts. 

H. A., 29 years old, servant-girl ; admitted May 9, 1896. The 
patient had diphtheria and small-pox when a child. In her 
eighth year she suffered with a disease of the left fibula. The 
disease in the upper arm began a year ago. Her menses did 
not begin until she was eighteen years old ; has always men- 
struated regularly. The patient gave birth to a child last August ; 
the child was weakly and died in four weeks of a birthmark, so 
the patient says. 

Present Condition. — The patient is of slender build and 
emaciated. Teeth are bad. Nose slightly saddle-shaped. The 
throat marked with scars. The remains of the soft palate are 
drawn against the posterior wall of the pharynx. Uvula is 
wanting. 

There is a radiating, movable scar over the acromion and 
clavicle on the left side. It represents the remains of an ulcer- 
ation which followed the patient's confinement last year. 
Shortly afterward an ulceration developed on the left upper 
arm and lasted two months. ' The contracting, radiating scars 
which remain are directly adherent to the bone. At the same 
period a stiffness began to show itself in the elbow-joint. At 
the beginning of the present year, when the disease on the 
back of the arm had hardly begun to heal, the ulcer on the 
front of the arm developed, and soon after that the one on the 
upper third of the forearm and in the bend of the elbow. The 
left arm is held in extension, the hand in extreme pronation. 
Flexure at the elbow and supination much impaired. The 
upper two-thirds of the radius seem to be thickened, as is also 
the lower end of the upper arm. The external surface of the 
upper arm is occupied by an ulcer 9 cm. long and 3 cm. wide, 
about the periphery of which a little scar-tissue is beginning to 
form, with here and there a few granulations. ^ The floor con- 
sists of necrotic muscle-fibers lying lengthwise, of a dirty yellow 
color and surrounded by irregular depressions which discharge 
a scanty secretion. Further down toward the elbow there is 
a raised wheal, and near its outer margin an oval ulcer about 
2 cm. in diameter. A bridge of scar-tissue about 1£ cm. wide 




Tab. 55. 






separates this ulcer from the one above it. The floor is 
formed by the brownish necrotic skin. The subcutaneous 
cellular tissue, macerated with serum, is exposed for about 
3 to 4 cm. from the edge of the dry crust of skin. Below this 
latter ulcer, close to the wheal, there is a third ulcer with 
seropurulent floor ; divided into two halves by a bridge of skin. 
Finally, on the upper third of the forearm and in series with 
this last-mentioned double ulcer, is one about 5 cm. long, the 
inner half of which, lying toward the radius, is covered with 
granulations and attached to the radius by scar-tissue. In the 
outer half of the ulcer is a fragment of skin on the point of 
desquamation, and brownish subcutaneous tissue, resting on 
a foundation containing a scant serous exudation, so that the 
necrotic parts are easily movable over the underlying tissue. 
This ulcer lies between the radius and the ulna, over the pro- 
nator radii teres muscle, and seems to have sprung originally 
from the radius. In the bend of the elbow is the above-men- 
tioned wheal with the two ulcers near its outer border. The 
lower third of the radius is enlarged from periostitis ; the upper 
part also thickened in irregular lines in the long axis of the 
bone. The ulna does not appear to be involved to the same 
degree. On the other hand, the entire lower third of the upper 
arm, almost as far as the middle, is enlarged and, with the 
exception of the large ulcer described, covered with scar-tissue. 
In some places the bone is reduced in thickness from atrophy ; 
in others it is enlarged from periostitis. 

On the outside of the left calf is a scar 10 cm. long, adherent 
to the bone, the result of the above-mentioned disease of the 
fibula. The genitals present no alterations. Several white, 
atrophic scars about the anus probably date from the attack 
of small-pox. The inguinal, as well as the other glands of the 
body are reduced in size. 



PLATE 56a. 
Destruction of the Soft Palate by Gummatous Ulceration. 

S. M., 25 years old. The patient does not know how long her 
disease has lasted. She only began to feel pain in the throat 
three weeks ago. 

" Present Condition. — At the edge of the labia majora sev- 
eral whitish, hairless, areolar scars. Similar, reticulated scars 
about the anus and in the vestibule. In addition, other scars 
on the inner surface of both labia minora. Inguinal glands 
hard and spindle-shaped. Almost the entire soft palate want- 
ing, the edges of the wound being covered with shreds of ne- 
crotic tissue. The ulceration has invaded the edges of the arch 
of the palate, so that the upper and lateral boundaries of the 
isthmus are also involved in the degenerative process. 

Cured by the application of fifteen inunctions and 64 g. (3ij) 
of potassium iodid internally. 



PLATE 56b. 
Gumma (on Posterior Wall of Pharynx). 

R. R., 39 years old, no occupation ; admitted Jan. 6, 1896. 
History very meager. Patient has been married eleven years ; 
says she has never been pregnant. For the last three years she 
has been troubled with a "nasal affection ;" she says the secre- 
tion has a very offensive odor. Regurgitation of soft and liquid 
food began quite suddenly a week ago. The patient's husband 
admits that he was infected with syphilis three years ago. 

Present Condition.— No remains of a syphilitic infection 
can be demonstrated on the genitals. At tbe anus a red scar 
about as large as a pea. Multiple swelling of the inguinal 
glands. 

The soft palate is destroyed and replaced by a scar; the 
uvula is entirely wanting. Strands of scar-tissue are attached 
to the posterior wall of the pharynx, on which there is an ellip- 
tical ulcer about lh cm. by \ cm., its long axis corresponding 
with that of the pharynx. The center is depressed and partly 
covered with a dry, black scab; near the edges it is slightly 
flattened. To the right of this ulcer the orifice of the Eu- 
stachian tube can be seen. Rhinoscopic and larjmgoscopic 
examination reveals no other alterations. 

Voice is nasal. The breath is very fetid. 

Treatment. — Inunctions and potassium iodid. 

After twenty-five inunctions the ulcer on the posterior wall 
of the pharynx healed over completely and was replaced by 
scar-tissue. 

Discharged Feb. 11, 1897. 



Tab 56. 



wuto^m 











PLATE 57. 
Gummatous Glossitis. 

A. F., 25 years old, servant-girl ; admitted Oct. 28, 1890. Un- 
der treatment one month. Second attack. Has had an ulcer 
on the tongue for three months. Five years ago the patient 
was under treatment three months in the syphilitic ward of the 
Wiedener hospital for a specific ulcer. 

Present Condition. — Ulcer on the right labium majus. No 
other signs of a former or still existing syphilitic attack either 
on the skin or in the glandular system. When the mouth is 
opened wide and the tongue well protruded a swelling is seen 
covering the entire posterior half of the left side. The tumor 
is raised 3 to 4 mm. above the surrounding surface; it is hard 
to the touch and extends through the entire thickness of the 
organ from its base to about its middle. The surface of the 
tumor is traversed by an ulcer 3 cm. long. From the middle 
of the tongue, extending almost to the tip, there is another 
tumor consisting of a number of nodular infiltrations, showing 
necrotic decay in three places. 

Treatment. — Potassium iodid. Antiseptic mouth-wash. 
On Nov. 17th an inunction treatment was inaugurated. The 
infiltration was absorbed and the ulcers healed. After fifteen 
inunctions the p'atient was discharged cured. 



PLATE 58. 
Papulopustular Exanthema. Hereditary Syphilis. 

(Obtained through the kindness of Dr. Braun, of the Found- 
ling Asylum.) 

S. K., about 4 weeks old, weight 5| pounds ; admitted July 8, 
1897. Marasmus marked. Suffering from bronchitis and in- 
testinal catarrh. The skin is pale and wrinkled, and thickly 
covered with a syphilitic eruption. The forehead and mouth, 
and also the trunk and extremities, are the seat of papules 
with pale-red border, or vesicles containing a small quantity of 
serous exudate, with flaccid, partly degenerated epidermis. 
Died after twenty-four hours. 

Autopsy. — General tabes, bronchitis, lobular pneumonia on 
both sides, enlarged spleen, hepatitis, gastro-intestinal catarrh, 
syphilitic osteochondritis at the epiphyses of the tibiae. 



Tab. 58. 




LittiAwt.v.F RpHihhilil.Munriit'ii 



PLATE 59. 
Papulovesicopustular Exanthema. Hereditary Syphilis. 

On the legs and on the soles of the feet papular and vesicular 
infiltration and vesicles, ranging in size from a lentil to a pea, 
containing pus and surrounded by an inflammatory halo. 

F. J., born June 9, 1897 ; admitted to the Foundling Asylum 
June 10, 1897. Weight at the time of admission 8^ pounds. 
Mother apparently healthy. 

On June 15th an eruption, consisting principally of papules, 
appeared on the palms of the hands and soles of the feet. On 
the following day the extensor surface of the lower extremities, 
the nates, and the back were also covered. Some vesicles and 
pustules are seen among the papules. The nose is not affected. 

Later on symptoms of bilateral lobular pneumonia and gas- 
trointestinal catarrh appeared. The baby's weight gradually 
fell to six pounds. Died June 26, 1897. 

Autopsy. — Lobular pneumonia in the lower lobes of both 
lungs, infiltration of the liver, enlarged spleen, gastro-intestinal 
catarrh, no osteochondritis. 



X> 

03 




PLATE 60a-c 
Hereditary Syphilis. 

(Parenchymatous keratitis ; syphilis of the bones of the nose ; Hutch- 
inson's teeth.) 

K. A., 20 years old, servant ; admitted June 5, 1897, to Pro- 
fessor Bergmeister's ward for diseases of the eye. The patient 
says his right eye was diseased nine years ago. The disease in 
the left eye began two weeks ago. Photophobia and excessive 
lachrymal secretion. 

Present Condition. — The entire body, though of normal 
build, is distinctly puerile for its age of twenty years ; the bones, 
especially those of the extremities, are soft and greatly enlarged 
at the joints; the genitals are infantile and the pubic hair very 
scantily developed. The compact, dolichocephalous skull pre- 
sents a marked contrast to the soft bones of the extremities. 
The bridge of the nose is sunken and saddle-shaped (see Black 
Plate 60c). The lips, especially the upper one, heavy and hyper- 
trophied. Upon inspection of the nasal cavity the cartilaginous 
as well as the bony portion of the vomer is found to be eroded 
by the destructive ulceration ; the probe strikes upon a rough, 
bony surface. When the upper lip is raised, it is seen that the 
necrosis has invaded the upper maxillary bone, a narrow bridge 
of alveolar process being necrotic as far as the margin and 
limited in front by a remnant of gum and by granulations. 
The teeth present the type of congenital syphilis described by 
Hutchinson : the irregular arrangement and chisel-shape, with 
notches in the margin. 

Ophthalmoscopic Examination (by Professor Bergmeister). 
— The right eye diverges; it is at present free from irritation ; in 
the center it shows traces of parenchymatous cloudiness. The 
pupil retracts promptly. 

The left eye: ciliary irritation ; the upper margin of the lim- 
bus is swollen, the adjacent zone of the cornea dim and granu- 
lar. A dense parenchymatous cloudiness encroaches upon the 
cornea from under the upper margin of the cornea. 



Tab. ( 



%, 1 



ss; 







Treatment. — Atropin ; inunctions ; potassium iodid. 
June 11. Congestion in the left eye has disappeared; slight 
turbidity in the upper half of the cornea. Discharged cured. 



Tab. 60 c. 




PLATE 61. 

Venereal Ulcers in the Foreskin and on the Head of the 
Penis. 

V. E., 26 years old, machinist ; admitted Sept. 17, 1896. This 
is his first attack. Patient had his last coitus two weeks ago ; 
he first noticed the ulcers ten days ago. 

On the left side of the inner layer of the prepuce are two 
large venereal ulcers, surrounded by a zone of moderate in- 
flammation. The edges are broken down and the floor dis- 
charges freely. Five smaller ulcers, about as large as lentils, 
below the larger ones, and one ulcer on the head of the penis 
represent the second generation of these auto-infective sores. 

The ulcers healed upon application of formalin-gelatin and 
cauterization with carbolic acid, leaving scars. 



CO 




PLATE 62. 

Contagious, Coalescent Venereal ulcers in the Skin of the 
Penis. Adenitis of the Right Inguinal Glands. 

K. J., 29 years old, coachman; admitted Nov. 26, 1896. 
Patient says it is his first venereal attack; first noticed the 
sores two weeks ago; last coitus three weeks ago. 

Present Condition. — In the skin of the penis, about its 
middle, is a large venereal ulcer formed by the confluence of 
several smaller ones ; a second smaller one nearer the end of 
the penis, separated from the first by a slender bridge of skin. 
Both ulcers have penetrated beyond the skin; the edges are 
sloping and irregular in outline ; the secretion of pus is copious, 
and the ulcers show a tendency to spread by undermining the 
adjacent skin. The surrounding tissues are inflamed, the 
lymphatics of the dorsum being red and distinctly visible. In 
the right inguinal region there is a tumor as large as a child's 
fist, red in the center, painful, and slightly fluctuating. 

Treatment. — Airol powder locally. Operation for the 
adenitis. Cured. 



PLATE 63. 

Paraphimosis from Venereal Ulcer on the Foreskin. In= 
flammatory Edema. Suppurative Adenitis in Both 
Groins. 

S. F., 21 years old, glove-maker; admitted Jan. 30, 1897. 
Last coitus seven weeks ago. Patient first noticed the ulcers 
four weeks ago ; the adenitis, two weeks ago. 

Present Condition. — Prepuce swollen and inflamed, re- 
tracted ; reposition impossible. Large, suppurating ulcers in 
the region of the frenum ; a smaller one on one of the folds 
of the retracted edematous prepuce. Inguinal glands swollen 
on both sides ; the skin over them inflamed, and beginning to 
ulcerate on the left side. Vesicular eczema of the pubic region 
from the abuse of gray ointment. 

Treatment. — Sulphate of copper baths, iodoform powder (for 
the ulcers). Operative removal of the suppurating inguinal 
glands. 

Later on, the ulcer on the frenum proved to be indurated, a 
papular Syphilide appeared on the trunk, and the patient bad 
to be subjected to inunction-treatment. 



^ 

C3 




PLATE 64. 

Suppurative Lymphangitis of the Dorsum Penis (Bubonu= 
lus Nisbethi), with Necrosis of the Integument. 

N. B., 22 years old, locksmith ; admitted Feb. 1, 1897. The 
ulcers appeared three weeks ago. Contraction of the foreskin 
and the swelling on the dorsum penis began eight days ago. 
Last coitus two months ago. 

Present Condition. — Preputial sac swollen and very much 
inflamed. A purulent secretion flows from the constricted 
opening. About the middle of the dorsum penis is a hemi- 
spherical tumor projecting above the surface, about as large as 
a walnut. The exposed surface is about as large as a penny, 
and presents a dark-brown discoloration. The tumor fluctu- 
ates. In front the necrotic scab is beginning to separate from 
the surrounding inflamed tissue. On pressure thin pus oozes 
from under the crust. Multiple swelling of the inguinal 
glands, especially of the right side. After a few days the 
abscess was evacuated, the necrotic covering fell off, and a large 
ulcer was exposed, the upper margin of which, lying toward the 
pubic region, appeared undermined, so as to simulate a fistula, 
while the floor was covered with a copious purulent secretion. 

Cured with sulphate of copper baths and iodoform powder. 
Paraphimosis removed by operation. 



PLATE 65. 
Abscess of the Left Gland of Bartholin. 

L. J., 19 years old, prostitute ; admitted March 10, 1896. 
Patient had no knowledge of her gonorrhea. Pain and swell- 
ing began six days ago. 

The left labium majus is converted into a painful inflam- 
matory tumor as large as a child's fist, red throughout its whole 
extent ; the skin toward the internal border thin and of a livid 
hue, with a distinct fluctuation beneath it. The tumor has 
pushed aside the right labium majus and the left genitocrural 
fold. 

Treatment. — Incision of the abscess. 



PLATE 66. 
Gonorrhoea Cavernitis. 

J. K., 22 years old, confectioner. Under treatment from Feb. 
12 to April 20, 1897. Had been ill eight days before admit- 
tance to the hospital ; last coitus two weeks ago. Acute gonor- 
rhea. 

In the course of the treatment in the hospital a marked swell- 
ing developed on the under surface of the penis, which was very 
painful on pressure. 

The member appears bent, the concavity looking upward. 
When fluctuation appeared to the right of the raphe of the 
penis, an incision was made and a moderate amount of creamy 
pus was discharged. 

Drainage. The wound healed nicely. Patient was discharged 
cured. 



PLATE 67. 
Condylomata Acuminata. 

G. S., 24 years old, servant-girl ; admitted Aug. 18, 1896. The 
patient says she has had a discharge for five months. The pro- 
liferating growth on the genitals began to develop two months 
ago. 

Present Condition. — The labia majora, the perineum as far 
as the anus, and the region extending to the genitocrural folds 
are covered with a massive tumor composed of wart-like, 
nodular papillomatous proliferations. The surface is macerated 
in places, in others covered with a layer of grayish-white hyper- 
trophied epidermis, and presents here and there isolated areas 
of bright-red discoloration. When the labia majora are held 
apart, the labia minora and vestibule appear much inflamed 
and covered with isolated and coalescent papillomatous prolif- 
erations. Urethral gonorrhea. Purulent discharge from the 
cervix of the uterus. 

Treatment. — Eemoval of condylomata under chloroform 
anesthesia. 



^/f^%m 




PLATE 68. 

Condylomata Acuminata on the Coronary Sulcus and on 
the Inner Layer of the Foreskin, which is Inflamed and 
Necrotic along the Left Border. 

(The illustration is a copy of the original by Elfinger in the 
collection of the hospital.) 

The left border of the foreskin has become necrotic from 
pressure and fallen off; the necrosis has also invaded the un- 
derlying tissue, which is now exposed. The right portion of 
the prepuce is displaced to the right and turned back. The 
space within this expanded preputial sac is occupied by the 
glans and the surrounding mass of condylomatous prolifera- 
tions. The latter are covered here and there with a greenish, 
discolored pus. 




München 



PLATE 69. 
Condylomata Acuminata at the Os Uteri. 

Cz. A., 19 years old, prostitute ; admitted Oct. 12, 1896. A 
month ago the patient was discharged from a hospital, where 
she had been treated for gonorrhea and condylomata acuminata. 
She says the condylomata returned four days (?) ago. 

Present Condition. — Acute urethral gonorrhea. Condylo- 
mata on the fimbria. Os uteri turned back and flattened ; on 
both lips, especially close to the anterior lip, confluent condylo- 
mata acuminata ; purulent discharge from the os uteri. 

Treatment. — Removal of the condylomata with the curet, 
after drawing forward the uterus. 

Discharged Dec. 22, 1896, cured. 



Tab. G9. 




F. Reichhold, München 



PLATE 70. 
Subcutaneous Hemorrhage into the Skin of the Penis. 

J. R., 39 years old, factory-hand. Under treatment from 
May 9 to 19, 1892. 

The patient noticed the present condition of the penis on 
May 8th, immediately after sexual intercourse. The woman 
with whom he then performed the act of copulation for the 
first time was, according to his statement, not a virgin, but was 
very closely built and he had to make a great effort to effect an 
entrance. The patient also says that he often has spontaneous 
attacks of epistaxis, and bleeds very freely after having a tooth 
pulled or from the least cut (hemophilia). 

Present Condition. — Vigorous, apparently healthy man. 
Nothing abnormal detected in the internal organs. Genitals 
well developed. Penis slightly edematous, especially the lower 
portion of the prepuce. The skin about the root is tense and 
of a dark, purplish hue. Color of the glans normal. The lower 
portion of the prepuce is converted into a purple, edematous 
tumor, somewhat larger than a walnut, and pendulous. 

Upon local application of cold compresses the extravasa- 
tion was absorbed, the skin passing through the usual color- 
changes. 



Tab. 70. 







PLATE 71. 
Molluscum Contagiosum (Moniliforme [bead=Iike] ) . 

M. W., 22 years old, washwoman; admitted Feb. 2, 1897. 
Has had a discharge for two weeks. Gonorrhea. 

A large number of pale-red nodules, ranging in size from the 
head of a pin to a pea, depressed at the center and pierced here 
and there by hairs, are seen disposed in rows on the outside of 
both labia majora and extending in a straight line to the but- 
tocks. 

Treatment. — Kemoval of the vegetations with the curet. 
Discharged Feb. 23, cured. 



Tab. 71. 




chhöld, München. 



INTRODUCTION. 



Syphilis, also called lues venerea, is a constitutional dis- 
ease, and is classed among the chronic infectious diseases. 

It is probable that syphilis, like tuberculosis, glanders, 
etc., is caused by a micro-organism, but the specific bacillus 
has not as yet been isolated. 

We cannot, in this short abstract of the pathology, enter 
into a discussion of the various attempts that have been 
made to explain the nature of the syphilitic virus, nor 
shall we even mention the theoretical descriptions and 
interpretations of the pathological products, which are 
based on the mere assumption of the existence of a 
micro-organism and its toxins. 

Syphilis can be transmitted from an infected to a healthy 
individual free from syphilis — acquired syphilis. It is, 
therefore, a contagious disease which follows inoculation 
with the virus and infects the entire organism, giving rise 
to various symptoms. 

In addition to this mode of infection, syphilis has the 
property of being transmitted from parent to offspring— 
hereditary syphilis. 

Depending upon these two modes of infection, the dis- 
ease presents in its subsequent course marked variations, 
so that the two varieties have for a long time been treated 
separately. We shall therefore adhere to the customary 
method in our short presentation of the pathology, a nil 
shall begin with acquired syphilis. Hereditary syphilis 
will be discussed later in a separate section. 

It shall be our task to study the morbid symptoms pro- 
duced by syphilis, and to endeavor in this way to acquaint 
ourselves with the nature of the disease. 

Acquired Syphilis is transferred to a healthy person 
sometimes mediately, but in the great majority of cases 

l 



2 SYPHILIS. 

immediately. A focus is formed at the point of inocula- 
tion, and from this focus the virus penetrates into the 
organism. In order that this may take place, it is neces- 
sary, first, that the virus multiply at the point of entry ; 
and, secondly, that it be diffused through the body by 
means of the lymph- and blood-channels. 

The latter process is gradual, and cannot be demon- 
strated by any known method of examination ; we are 
therefore limited in our observations to the local manifes- 
tations at the point of entry of the poison, and to the 
symptoms immediately following, until other morbid 
symptoms make their appearance in other parts of the 
body. It is well to bear in mind, however, that the pro- 
cess of multiplication and extension of the virus through 
the organism is probably a continuous and uninterrupted 
one. The patient soon begins to complain of more or less 
subjective disturbance, and visible as well as palpable 
objective changes in the integument make their appear- 
ance, so that a complete general infection can be definitely 
recognized a few weeks after infection. 

For the sake of clearness and convenience, rather than 
in accordance with the actual conditions, the syphilitic phe- 
nomena are divided into (1) a primary stage, comprising 
the initial local symptoms produced by the infection ; (2) 
a secondary stage, beginning with the first appearance of 
the general symptoms ; and (3) a tertiary stage, in which 
nodular formations, so-called gummatous neoplasms, de- 
velop. Some specialists base this classification on the 
clinical appearance of the symptoms ; others, on the 
period at which they are observed to occur. As a mat- 
ter of fact, the division does not correspond with the 
actual nature and course of the disease ; for, although 
there are so-called latent or intermission-periods during 
which the organism is apparently free from the symp- 
toms of the following group, we know that the virus 
continues to live and multiply within the body, and 
sooner or later gives rise to renewed symptoms. Per- 
haps it would be more exact to designate the primary 



INTRODUCTION. 3 

and secondary symptoms together as the irritative stage, 
as Virchow did long ago, separating them from the later 
gummatous neoplasms and degenerations of single organs 
which may or may not develop. 

It is impossible to foretell in a given case how many 
more symptoms will appear in the organism, or how 
severe a course the disease is destined to run. No favor- 
able prognosis can be based on the mildness either of the 
initial symptoms at the point of infection during the pri- 
mary period, or of the general symptoms in the skin and 
mucous membranes during the secondary period. Judg- 
ing by our own experience, we can only say that strong, 
healthy individuals justify the hope that they will easily 
get over the disease, while patients who have been weak- 
ened by tuberculosis, malaria, or even by intercurrent 
diseases, will probably suffer more under similar condi- 
tions. It is therefore important to be even more cautious 
in prognosis with such individuals than in the case of 
otherwise healthy subjects. Very young, undeveloped 
individuals, and children who have become infected with 
svphilis, suffer more severely, as the tender, growing or- 
ganism falls an easy prey to the ravages of the disease. 
The physician is therefore unable to say definitely to a 
patient that his malady will come to an end at such and 
such a time with such and such a symptom. As a rule, 
syphilis terminates with the irritative stage or the so- 
called secondary symptoms. Unfortunately, however, in 
many cases gummatous neoplasms develop in spite of the 
most careful treatment and management, and these neo- 
plasms are capable of damaging the organism more than 
the milder inflammatory and infiltrative processes of the 
secondary period. In spite of the efforts of many skil- 
ful specialists, no definite signs have yet been discovered 
which enable the physician either to pronounce an attack 
of syphilis definitely ended, or justify him in expecting 
the occurrence of tertiary symptoms. Until new methods 
of examination are discovered which shall enable us to 
pronounce a body free from syphilis, we shall be forced 



4 SYPHILIS. 

to rely on certain empirical facts to determine whether or 
not the disease is permanently cured. These facts are : a 
healthy, vigorous condition of the general system before 
syphilis is acquired; a certain regularity in the appear- 
ance of the symptoms; the effect of appropriate treat- 
ment; and, finally, freedom from any symptom of the 
disease for a number of years. The following scheme 
will be found to hold good for most cases : 

The interval from the time of infection to the appear- 
ance of secondary symptoms is about eight weeks. This 
period includes the development of the initial induration 
— within the first three weeks — the involvement of the 
neighboring lymph-glands and sometimes of the lym- 
phatics leading to them, and subjective disturbances, com- 
plained of by some patients before the appearance of the 
rash. The first rash disappears, and after about three 
months — that is, six months after infection — a Syphilide 
usually develops in some of the mucous membranes. The 
subsequent course of the disease is characterized by the 
appearance, at irregular intervals, of localized rashes 
which yield to appropriate treatment. With the end of 
this period, which usually lasts from one and a half to 
two years, the disease itself usually terminates. 

An exception to this scheme is formed by the more 
malignant cases, in which there are no intervals of free- 
dom from the disease, tertiary and secondary symptoms 
occur together, and nervous disturbances and general 
systemic disease manifest themselves early. These con- 
stitute the malignant forms of syphilis. Between these 
two varieties, in point of frequency, are those cases in 
which tertiary forms develop after a latent interval, dur- 
ing which the patient is entirely free from all symptoms. 

THE PRIMARY STAGE OF ACQUIRED SYPHILIS. 

Conditions of Infection, 

Certain conditions are necessary for the infection of an 
individual with syphilis. In the first place, he must be 



PRIMARY SYPHILIS. 5 

free from the disease ; and, secondly, there must be some 
loss of epithelium or epidermis — in short, some sort of 
wound — on the surface of the body for the infection to 
take place. 

Syphilis in attacking an organism renders it immune 
against subsequent infection for a long time. It is true, 
even such an immune individual may be infected by an 
ulcer; but it is only an apparent syphilitic infection, 
since the ulcerative process which results is always purely 
local and entails no further consequence to the organism. 

The abrasion, which is probably the most important 
condition of a syphilitic infection, may either be effected 
at the time of exposure — for instance, during coitus ; or 
it may have existed before infection took place — for in- 
stance, an erosion after herpes prseputialis or labialis. 
Syphilitic infection may, it is true, take place even if the 
tissues are not injured, but only if they are in a certain 
condition and the secretion which contains the syphilitic 
virus acts for a long period of time, setting up an irrita- 
tion in the ducts of glands or in the delicate mucous 
membranes (preputial sac, rima pudendi) ; while on the 
other hand, even very short contact with an open wound 
is followed by infection. 

Whether the infection occur through direct contact 
with a syphilitic body (immediate infection) or through 
some object polluted with the secretion of a syphilitic 
sore {mediate infection), the subsequent course of the dis- 
ease is the same. 

Channels of Infection. 

An individual in the acute — that is, the completed, in- 
fectious — stage of syphilis is justly considered a menace 1 
to his surroundings. The virus is most abundant in the 
secretions of syphilitic ulcers, but it is also present in the 
blood and lymph during these stages. It is not contained 
in the normal secretions of the body, as the saliva, milk, 
and seminal fluid, although even these may become mixed 



6 SYPHILIS. 

with the virus on their way through the organism or at 
the points where they reach the surface, the oral cavity, 
the mamma, and in disease of the very vascular testicles 
which may not be demonstrable clinically. Persons with 
acquired as well as with hereditary syphilis, as, for in- 
stance, children with syphilitic pemphigus and papillo- 
mata, are a source of danger to a non-syphilitic organism 
for many years. Recent observations have shown that 
old sores which scarcely inconvenience the patient may 
give the infection long afterward, if they happen to be- 
come raw through maceration or some mechanical means. 
We may mention in this connection old anal and perianal 
infiltrations, tongue affections, and many other so-called 
places of predilection of the syphilitic products which will 
be discussed later. 

It is generally held that the tertiary syphilitic products, 
the so-called gummatous neoplasms, cannot carry the 
infection, but the statement must be taken with a reser- 
vation. Thus, cases in which tertiary coexist with sec- 
ondary symptoms, and which therefore belong to the 
group of tertiary forms, unquestionably do carry the 
infection. Still, the infective power of gummatous pro- 
cesses is undeniably weaker than that of secondary lesions, 
the principal reason probably being that the gumma dis- 
integrates much later, after the infiltration has undergone 
a retrogressive metamorphosis, so that nothing is left 
but a detritus in which the syphilitic virus has become 
weakened or even destroyed. Another reason is that the 
gummatous forms are often localized in situations from 
which infection is impossible (internal organs), and, 
finally, the patients themselves dread and avoid contact 
with the gummatous ulcers on account of the pain it gives 
them. The secondary lesions, on the other hand, which 
lie more superficially and disintegrate very soon after 
they are formed, result in extensive tissue-destruction 
with copious secretion which is much more likely to 
carry the infection than that of gummatous ulcers. 

Old ulcers resulting from gummatous wheals and tissue- 



PRIMARY SYPHILIS. 7 

alterations, like hyperostoses and eburnations in the bones, 
are to be regarded as the remains of old syphilitic prod- 
ucts in those situations and contain no virus. 

So far we have mentioned only human syphilitic bodies 
as carriers of the virus, but, in addition, a great variety 
of objects, such as spoons, glasses, wind-instruments, sur- 
gical instruments, bandages, etc., are capable of carrying 
the infection if they have previously come in contact 
with syphilitic wounds and some of the secretion has 
stuck to them. Desiccation of the syphilitic secretion 
does not render the virus harmless. Very high temper- 
atures or freezing, on the other hand, so far as our pres- 
ent experience goes, are capable of destroying the virus. 

The First Phenomena that Appear after Syphilitic 
Infection. 

The first phenomena that appear after infection possess 
no characteristic features on which to base an opinion as 
to the effectiveness of the infection. They comprise 
wounds which existed before the suspected infection, 
or of fresh lesions sustained at the time of infection, 
or of macerations of the epithelium or epidermis in 
the region of the above-mentioned folds or ducts of 
glands, usually about the genitalia. The patients rarely 
consult a physician at this period unless they are in the 
habit of observing themselves closely and are aware that 
the lesion is directly due to contact with a foreign body. 
Persons who know nothing about syphilis or have been 
infected indirectly are often very slow to seek medical 
assistance, sometimes not before secondary symptoms 
have developed throughout the entire body. It follows 
from what we have said that the physician is seldom in a 
position to say, shortly after the occurrence of infection, 
more than that the erosion, or skin-lesion, or ruptured 
vesicles (as, for instance, after herpes) have a more or less 
suspicious look ; ho might perhaps determine by an ex- 
amination of the individual suspected of being the source 



8 SYPHILIS. 

of the infection, whether he has to deal with a syphilitic 
affection or not. 

It makes a difference whether the infection is due to 
syphilitic products alone, or whether a purulent secretion 
from a venereal infectious sore was inoculated at the same 
time. In the former case we have a slowly develop- 
ing ulcerative process, or rather a gradual infiltration in 
the affected area ; while in the latter case the acute course 
of the venereal ulcer, its rapid disintegration and profuse 
purulent secretion conceal the signs of syphilitic infec- 
tion so effectually that it is only after the ulcer has healed 
that the specific nature of the process is recognized. All 
wounds of this kind, even venereal infectious ulcers, can 
be completely cured by antiseptic treatment and careful 
management ; but it does not necessarily follow that the 
entire morbid process is ended. Infiltration often develops 
after scar-formation, the neighboring groups of glands be- 
come swollen, constituting a true initial infection, which 
produces the same effects on the organism as if it had 
originated in a simple syphilitic ulcer. 

As a rule, however, the small, insignificant abrasions 
are gradually converted into rounded ulcers, spotted on 
the surface, which give but a scanty secretion and cause 
little discomfort to the patient. In the course of the 
second, and especially the third, week the typical infil- 
tration develops at the base and near the periphery ; it 
takes on a spherical nodular form, is hard to the touch, 
and represents the so-called induration or sclerosis 
(PL 1). The degree of infiltration depends on the local 
nature of the tissue in which the infection takes place. 
Thus, for instance, we frequently see on the glans penis 
and at the vaginal orifice flat infiltrations, eroded on the 
surface (erosio superficialis sclerotica). On the surface of 
the body, especially where the skin is loosely attached 
to the underlying tissue, we find nodular, hard infiltra- 
tions, elevated above their surroundings, which attain 
their greatest extent in parts covered with hair and 
rich in glands (Plates 2 to li). We have seen such an 



PRIMARY SYPHILIS. 9 

induration about the size of a half dollar on the chin, 
which closely resembled a neoplasm, and it is not so very 
long ago that such syphilitic indurations on the lips, breast, 
etc., were mistaken for epitheliomata. If such initial le- 
sions are situated in parts much subject to traction, as, for 
instance, at the corners of the mouth, at the junction of 
palate and tongue, in the tonsils, the anus, etc., they take 
the form of ulcerative fissures, and often complicate the 
diagnosis of induration by the rapid disintegration of the 
infiltrate. Syphilitic tissue in general, particularly an ex- 
tensive induration, rapidly undergoes gangrenous decay 
from pressure or traction, so that the induration disap- 
pears and a large ulcer is formed. In the same way 
inappropriate treatment, especially useless, unnecessary 
cauterization, may cause the infiltrate to break down, 
and lead to the formation of a large ulcerated surface. 
From the point of infection the syphilitic virus pene- 
trates into the body through the lymph- and blood-chan- 
nels. The lymph-capillaries especially take up the greater 
part of the tissue-juices flowing back from the periphery, 
and, uniting to form larger vessels, carry it to the nearest 
glands. The returning blood-vessels, the veins, also no 
doubt take up the virus from the induration and carry it 
to the rest of the body ; but in the case of the lymphatics 
we have clinical and histological proof. Whoever has had 
the opportunity to observe a large number of cases will 
remember many in which the tissue immediately sur- 
rounding the induration was swollen and almost as hard 
and unyielding as the induration itself, was edematous to 
the touch, and sent out hard, tough cords to some distance, 
easily traceable to the glands of the region, — for instance, 
along the dorsum of the penis when the induration was 
seated in the prepuce. These changes begin with a cap- 
illary or cord-like lymphangitis with nodular swellings. 
If the lymphangitis is very superficial, or the nodular 
swellings are extensive, superficial excoriations or even 
complete decay not infrequently result. Such nodular 
ulcers may appear like so many separate points of infec- 



10 SYPHILIS. 

tion ; sometimes a lymphangitis of this character, follow- 
ing upon the initial lesion, may give rise to extensive 
swelling and result in a high degree of deformity involv- 
ing the entire genitalia, a very obstinate condition which 
has been designated indurative edema (Plates 5, 
12). It usually yields to general treatment and disappears 
entirely upon the advent of secondary symptoms. This 
variety of indurative edema is to be distinguished from 
acute inflammatory edema, an acute process which may 
accompany any septic or ulcerative wound, and occasion- 
ally leads to abscess-formation in the course of the lym- 
phatics, as in venereal ulcer (bubonulus Nisbethii). 

Swelling of Lymph=glands. 

A constant phenomenon in the subsequent course of a 
syphilitic infection is swelling of the lymph-glands near- 
est the point of infection, indurations of the genitalia of 
the inguinal glands, induration of the mouth and lips 
(Plates 9, 10), of the submaxillary and submental 
glands, etc. It is the outward expression of a widespread 
round-celled infiltration which now attacks the lymph- 
glands themselves, after running its course in the initial 
induration and the lymphatics leading from it. The 
swelling is usually moderate in simple syphilitic ulcers 
and causes little discomfort to the patient. But in degen- 
erating ulcers and in cases of mixed infection the glandu- 
lar irritation is much more intense. The swelling is often 
so great as to form tumors as large as the fist, which break 
down at various points and present a so-called strumous 
adenitis. It often occurs in individuals weakened by 
scrofula, tuberculosis, etc., even when the peripheral irri- 
tation is comparatively slight. 

Phimosis and Paraphimosis. 

There is one very frequent complication of the initial 
form in the male organ, especially in the prepuce and 
neck. In such cases the prepuce, owing to the infiltra- 



SECONDARY SYPHILIS. 11 

tion surrounding the induration, becomes completely im- 
movable and rigidly adherent to the glans (PL 12). Such 
phimoses develop even when the fore-skin was origi- 
nally quite loose, and are sure to occur if even a slight 
constriction was present. The constant pressure leads to 
resolution and not rarely to gangrene of the indurated 
area. If the gangrene is not checked, the prepuce be- 
comes perforated and the glans may slip through the 
opening thus formed. We have seen cases in which the 
gangrene had completely destroyed the prepuce and had 
even spread to the skin of the penis and of the scrotum, 
so that the corpora cavernosa as well as the testicle and its 
supplying vessels were exposed. If such an infiltrated 
prepuce, before it becomes quite immovable, is forcibly 
pushed back, reposition is rarely possible (paraphimo- 
sis). The prepuce becomes edematous ; and the neck of 
the penis undergoes necrosis. The circulation in the glans 
and in the retracted prepuce is impeded and, if the con- 
dition persists for some time, the edema is replaced by a 
permanent inflammatory infiltration, reposition of the pre- 
puce is no longer possible, and a permanent deformity of 
the penis results. 

THE SECONDARY STAGE OF SYPHILIS. 
Prodromal Symptoms during the Eruptive Period. 

While the local symptoms are developing with more or 
less intensity, the virus penetrates into the system from the 
point of infection by way of the lymph- and blood-chan- 
nels, without other changes than those we have mentioned 
manifesting themselves for some time, usually until the 
fifty-seventh day after infection. The cases are, however, 
not uniform by any means. In a large proportion (per- 
haps more than half) the presence of grave systemic dis- 
ease betrays itself by certain subjective symptoms during 
the period when the disease is spreading through the 
body, without manifesting itself by any marked external 
changes. The patients complain of lassitude and depres- 



12 SYPHILIS. 

sion many days before the breaking out of the exanthema ; 
they are pale, with black rings under the eyes — in short, 
they have a distinct morbid appearance. At the same 
time they complain of pains localized in different portions 
of the body : headache, intercostal neuralgia, pain on press- 
ure in the sternum, especially near the points of union 
with the costal cartilages, without any demonstrable swell- 
ing, tenderness in single joints or groups of muscles, etc. 
The latter are sometimes called rheumatoid pains and are 
often mistaken for incipient rheumatism. The patients 
also exhibit a certain unrest and abnormal excitability, 
which in some persons merely take the form of irritability 
and moodiness, but in others, who had before been quite 
well, bring on violent palpitations of the heart at the 
least exertion, such as going up-stairs. Such patients also 
suffer from insomnia, either without any direct cause, or 
in consequence of the pains which usually increase toward 
nightfall, so that the general health becomes impaired. 
The symptoms we have referred to may be present singly, 
or several at the same time. A few patients have a slight 
rise in temperature of from 0.5° to 1°, toward evening, 
but this is the exception (syphilitic fever). 

After a variable interval, usually from a week to ten 
days, these symptoms gradually disappear, often without 
any treatment, and the exanthema develops, which brings 
us to the so-called secondary period. 

It will be well to mention now, before taking up the 
other morbid products of the secondary period of syph- 
ilis, that as a rule there is a gradual swelling of the pal- 
pable glands (general syphilitic glandular swelling) in the 
most varied regions of the body, usually observed about 
the same time as the first appearance of the general 
symptoms. The supraclavicular, cervical, nuchal, retro- 
auricular, the axillary, cubital, and other glands are 
found, either all or only in groups, to be somewhat 
increased in size and considerably indurated. The con- 
dition is most marked in scrofulous and anemic or other- 
wise debilitated subjects. 



SECONDARY SYPHILIS. 13 

Even in later stages of the disease the lymphatic sys- 
tem plays an important part, both independently and in 
connection with ulcerative processes in the skin. In the 
secondary period we also have enlargement of the spleen, 
which, however, is difficult to detect and does not occur 
in every case. We shall return to these pathological 
alterations in a later section. 

The Syphilitic Exanthemata. 

The syphilitic exanthemata of the secondary period are 
divided, accordiug to their histological appearance and 
clinical course, into three groups — macular, papular, and 
pustular. In addition, so-called squamous forms occur 
in very rare cases as a result of the papular exanthemata ; 
they are called squamous because they early show a ten- 
dency to superficial desquamation (PL 20). 

The syphilitic exanthemata exhibit certain general 
characteristics regularly seen in all forms. The rash is 
usually distributed symmetrically over both sides of the 
body and follows the fibers of the skin, especially in 
copious eruptions. Thus, for instance, on the back the 
eruption is disposed in parallel rows running obliquely 
downward on both sides (PL 16). Again, all syphilitic 
exanthemata, whether they appear singly or in groups of 
greater or less extent, as in the advanced stages, have a 
round or elliptical form (PL 21). This property, which 
is also found in other forms of dermatitis, probably de- 
pends on the distribution of blood-vessels in the skin. 
Lastly, it must be borne in mind that the eruption is 
only exceptionally uniform, in by far the greater number 
of cases it is polymorphous (PL 10). We observe either 
a direct transition of single eruptions from one form to 
another (for instance, from the macular to the papular) or 
one variety developing within another — for instance, pap- 
ular forms in a group of macular eruptions, papular in a 
pustular group, with varying characteristics (PI. 18). 

The Macular Syphilide. — We distinguish two forms 



14 SYPHILIS. 

of macular syphilides, syphilitic roseola and the large 
macular Syphilide. 

Roseola, the true representative of the hyperemic stage, 
chiefly affects the trunk ; the macules are brownish-red in 
color and about as large as a lentil or a pea ; they are not 
as a rule raised above the level of the skin, disappear on 
pressure, and may vanish completely, without leaving a 
trace, in a few days (three to twelve). As subjective 
symptoms are entirely wanting, this form of syphilitic 
eruption almost always escapes the patient's notice (PL 
13). 

The large macular Syphilide occurs later than roseola, 
often in combination with papular forms, in the genitalia, 
on the anus, in the mouth, etc. In the lower part of the 
body the color is livid, in the upper it is of a distinctly 
coppery hue. The individual lesions, which on account 
of their size are called maculae majores to distinguish 
them from those of roseola, called simply maculae, have 
received various names according to their shape and dis- 
tribution — Maculae majores figurata?, Maculae majores gy- 
ratae, Maculae majores annulares, etc. Their formation 
depends either on the coalescence of several adjacent pus- 
tules or on the disappearance of the redness in the center 
and increased redness in the periphery of single pustules, 
causing these rings to appear more distinctly. 

Most large forms of Syphilide are slightly raised above 
the level of the skin, and hence resemble various forms 
of polymorphous exudative erythema. They can easily 
be distinguished from the latter, however, by their longer 
duration, the entire absence of subjective symptoms, and 
by other accompanying symptoms. 

The large form of Syphilide is not a mere hyperemia of 
the skin, as Biesiadecki has shown, but depends on round- 
celled infiltration about the blood-vessels in the affected 
area ; it is therefore the first indication of the infiltrations 
that are characteristic of the papular stage. 

As has been stated, roseola disappears without leaving 
any appreciable changes in the skin. In the large form, 



SECONDARY SYPHILIS. 15 

on the other hand, we observe in rare instances a slight, 
barely noticeable desquamation of the epidermis in the 
affected areas after the disappearance of the eruption. 
More frequently the pigmentation disappears, so that the 
affected parts appear white and lead to the formation of 
cutaneous leukoplasia (Plates 14, 15, 16). 

The Papular Syphilide. — The commonest of the 
syphilitic eruptions of the skin, the so-called syphilides, 
is the papular form. It is often the first exanthema to 
appear after general infection of the organism, and runs 
its course either alone or combined with the macular or 
the pustular form. ' The base of the papule originally 
consists of a round-celled infiltration in the papillary 
layer of the skin, the size and shape of the papules 
depending on the extent and bulk of the proliferated 
tissue. In general appearance it is the most variable 
form of Syphilide. We may have nodules ranging in 
size from a millet-seed to a bean, or more flattened pap- 
ules, sometimes as large as a five-cent piece, presenting 
slightly raised edges and a somewhat depressed center. 
In recent cases of syphilis the papules are scattered over 
the entire integument, while in cases of longer standing 
they appear localized in the genitalia, the anus, the palmar 
surfaces, the mucous membrane of the oral cavity, etc. 
An opinion as to the gravity of a particular case may be 
formed from the shape and size of the individual papules. 

The lenticular Syphilide appears in collections of red 
nodules on the trunk and on the extremities. After a 
relatively short duration — eight to fourteen days — the 
individual nodules begin to show a dirty white discolora- 
tion and desquamate. This form of papular Syphilide 
usually leaves no permanent marks (PI. 17). 

The smaller, so-called lichenoid Syphilide usually attacks 
scrofulous or tuberculous individuals. It is almost never 
distributed evenly over the surface of the body, but occurs 
in groups of ten to twenty nodules. The individual pap- 
ules rarely show much hyperemia on their first appear- 
ance, and soon undergo a yellowish discoloration, suggest- 



16 SYPHILIS. 

'ing the picture of scrofulous lichen, especially if the 
eruption is copious. This form often persists a long 
time in spite of the most energetic treatment, and when 
it finally does yield, the nodules at first desquamate on 
the surface, but in the end the scabs come away bodily 
and leave minute punctiform depressions in the skin 
(Plates 19, 20). 

Another form is the flat, glistening, papular Syphilide 
(papulce nitentes), which is usually observed on the nose, 
in the nasolabial furrows, on the forehead — in short, on 
the face generally. The individual papules exhibit a 
pale-red, shining surface, moderately raised, sharp edges, 
and a slightly depressed center. With proper treatment 
the papules desquamate and disappear, usually without 
leaving any visible alterations in the skin (PI. 25). 

Orbicular papules (PL 21) constitute a late form which 
frequently occurs in relapse and affects the seats of pre- 
dilection (genitalia, anal region, etc.), or in connection 
with diseased organs (eye). The individual papules 
appear in the form of larger or smaller rings, according 
to the duration, exhibiting a slight depression with brown- 
ish pigmentation in the center, and separated by raised 
edges from the normal epidermis. The exudation at the 
borders of the papules is sometimes so profuse that the 
epidermis is loosened and forms a dry crust about the 
papule. As the sores begin to heal, the edges gradually 
flatten out and the center slowly regains its normal color 
by desquamation. 

In conclusion, we may mention the grouped variety of 
papular syphilides (tubercula cutanea [ßicord], papulae 
cumulis coaeervatse). This nodular form of Syphilide 
occurs only in the later stages of syphilis, often associated 
with bone- and joint-affections, occasionally with true 
serpiginous ulcers. The individual groups vary in size 
from a half dollar to the palm of the hand, and are made 
up of infiltrates as large as a pea, occupying the entire 
thickness of the skin and covered either with layers of 
dead epidermis or with a thick, dry crust. The skin 



SECONDARY SYPHILIS. 17 

between these raised nodules exhibits a dark-red or brown 
pigmentation. This form of papular Syphilide may per- 
sist for many months. It finally disappears either by 
absorption and superficial desquamation, resulting merely 
in a shallow depression in the epidermis, or by ulceration 
and superficial crust-formation, leading to deep scar-for- 
mation and permanent alteration of the affected area 
(Plates 22, 23). This late form of nodular Syphilide 
resembles the destructive forms of the gummatous stage 
in its mode of healing, and is sometimes classed as a 
superficial cutaneous gumma. 

The Pustular Syphilide. — The pustular syphilides 
cause vastly more discomfort to the patient than do the 
macular and papular forms. They rarely occur as an 
initial eruption, being preceded by macular and papular 
forms in the great majority of cases. Papular and pus- 
tular rashes sometimes exist together. There are cases, 
however, where the pustular Syphilide constitutes the 
initial eruption, and these cases deserve special attention 
because they represent a more acute and rapid form of 
syphilis, in the prognosis of which the physician should 
be exceedingly cautious. 

An eruption of pustular Syphilide is usually preceded 
by grave general symptoms. There are evening rises in 
temperature ; the patient looks pale and weak, he ex- 
hibits a strange restlessness, and often complains of las- 
situde, headache, and pains in the limbs. In this stage 
of syphilis we often meet with disturbances which point 
to disease of internal organs — for instance, icterus, al- 
bumin in the urine, etc. (PI. 18). 

We distinguish several forms of pustular Syphilide. 

Very often the eruption is characterized during its 
development by copious seropurulent exudations, the 
epidermis is loosened, and the pustules take on the ap- 
pearance of vesicles — the so-called vesiculous Syphilide 
(variola syphilitica). Later, the epidermis, together with 
the contents of the vesicle, forms a dry scab which is cast 
2 



18 SYPHILIS. 

off and exposes the papillary layer. In most cases a 
newly formed epidermis is seen under the scab. 

To this variety belongs the pustula minor, also called 
acneiform Syphilide; the individual nodules resemble a 
papule with a purulent vesicle in the center. The affected 
areas usually correspond to the openings of the hair-fol- 
licles and ducts of sebaceous glands. The vesicle is soon 
converted into a brown scab which covers the dome of 
the pustule (PI. 27). 

The most important representative of the group is the 
pustula major. This pustular Syphilide occurs either alone 
or in combination Avith the acneiform variety, and is 
characterized by its size, rapid disintegration, and a ten- 
dency on the part of the individual pustules to coalesce. 
The patient complains of burning pain, which is produced 
by the Syphilide itself and becomes greatly aggravated 
when the clothing or bed-linen sticks to the freely secret- 
ing pustules. The crusts are frequently torn off and 
replaced by deep ulcers with a dirty white floor, which 
gradually destroy the entire infiltrated papillary stratum. 

If the pustule spreads out superficially instead of 
attacking the deeper tissues, we get the so-called ecthyma- 
pustule (Plates 28, 29). 

Sometimes the crusts which cover the pustules grow 
upward. The exudation proceeds slowly and gradually ; 
the secretion dries as fast as it is produced ; the scab in- 
creases in thickness, and, as it extends peripherally at the 
same time by the melting of the tissues, new scabs are 
constantly added, and a formation resembling oyster- 
shells is produced, to which the term syphilitic rupia is 
applied (Plates 44, 45, 49). 

The subsequent course is the same in all forms of pus- 
tules — they heal by cicatrization. The scars frequently 
exhibit hyperemia and infiltration for some time. At last 
the hyperemia disappears, and the scar atrophies and 
becomes loose, white, and glistening, with an encircling 
zone of brown pigmentation. The alteration is perma- 



SECONDARY SYPHILIS. 19 

nent and especially noticeable on parts of the body covered 
with hair, if the roots of the hairs have been destroyed. 

In conclusion, we would mention a phenomenon which 
rarely accompanies pustular syphilides. The individual 
pustules are surrounded by an irregular, bright-red zone 
several millimeters in thickness and resembling the ery- 
thema of erysipelas. Whether this is caused by the 
breaking down of the tissue alone or by the generation 
of toxins, we shall have to leave undetermined. One 
point should be emphasized : whenever we have observed 
this phenomenon the patient was much reduced and pre- 
sented the appearance which is commonly seen in grave 
febrile diseases. 

Syphilides with Cutaneous Hemorrhages. 

Hemorrhagic syphilides are divided into two classes. 
The first class includes cases in which syphilis is com- 
plicated with another disease — for instance, hemophilia, 
scorbutus. Here the hemorrhage is a symptom of the 
complication, showing itself in the blood-vessels already 
suffering from the effects of syphilis. 

The cases forming the second class are less numerous. 
In these the formation of papular or pustular exanthe- 
mata is accompanied by hemorrhages in the affected areas 
from the start, and without the coexistence of other dis- 
ease, so that the hemorrhages must be regarded as the 
expression of disease of the vessels due to syphilis as 
such. The blood should be examined to determine 
whether the hemorrhages might not be in part due to 
grave blood disease. 

The fact that the occurrence of such forms always 
points to grave disease of the general organism must not 
be overlooked in the prognosis, whether we have to deal 
with a grave complication of syphilis or with a particu- 
larly malignant form of the disease itself. 

In the first series of cases the complicating affection 
must, of course, receive suitable treatment, just as in the 



20 SYPHILIS. 

second class the ulcers which almost always appear must 
be treated by suitable local measures in addition to the 
general treatment. 

We shall discuss this question more in detail when we 
come to speak of treatment. 

Abnormal CoIor=changes. 

In most syphilides there is a shifting of the pigmenta- 
tion ; that is to say, the pigment disappears in the sore 
itself and becomes increased around its periphery. This 
is particularly the case in parts naturally rich in pigment, 
as the nape of the neck and the genital region. Occa- 
sionally the entire surface of the body is thickly covered 
with pale, non-pigmented circular or oval spots. If they 
come under observation early enough, the center is seen to 
be reddish and the periphery white, while the immediate 
surroundings are darkly pigmented. Later the entire area 
becomes white and appears the more distinctly for the 
darker pigmentation of the surrounding parts. This so- 
called syphilitic leukoplasia (Plates 14, 15, 16) is a 
more valuable sign than any other, as it may represent 
the remains of a cutaneous Syphilide of very long stand- 
ing, and forms a diagnostic point of the highest importance 
in doubtful cases of diseased organs, such as retinitis or 
endarteritis. 

Many syphilides, especially such as are accompanied by 
great hyperemia, possess a directly opposite property of 
depositing large masses of pigmentation, which, if the 
eruption continues for a long time, leave dark-brown 
spots usually on the dependent portions of the body, 
persisting long after the disappearance of all other 
symptoms. 

Finally, we may mention the pigment-destruction which 
sometimes results from the disintegration of pustular syph- 
ilides, destroying the papillary layer and persisting for life 
as whitish, thin, atrophic scars (PI. 24). 



SECONDARY SYPHILIS. 21 

Diseases of the Hairy Scalp. 

During the secondary period of syphilis a variety of 
seborrhea of the scalp often develops, differing in many 
essentials from ordinary seborrhea. Instead of increased 
secretion, with desquamation of the epidermis, there is 
diffuse infiltration of the papillary layer and of the hair- 
follicles. The epidermis comes off in scales ; the hair 
loses its color and gloss, and is easily pulled out, or even 
comes out of its own accord. The resulting baldness is 
usually fairly uniform (diffuse alopecia). Sometimes the 
disease presents the type of a papular Syphilide, the hair 
is massed in thick bunches, and the loss of hair is confined 
to sharply defined areas about as large as a bean (areolar 
alopecia). The hair may be restored in both diffuse and 
areolar syphilitic alopecia. Unless the condition has lasted 
too long, lanugo hairs grow in three or four months, and 
are later replaced by strong, healthy hairs (PL 26a, black 
and colored). 

The loss of hair is, of course, most marked in the 
scalp, but it is to be remembered that analogous pro- 
cesses may also affect the eyebrows, eyelids, and more 
rarely the axillae and pudenda. 

Pustular Syphilide is a more common affection of the 
scalp than the above-mentioned diseases. Infiltration 
appears around the hair-follicles or attacks the roots 
themselves, so that while the hairs are still held fast on 
the surface by the incrustation, they die and become 
loosened within the scalp itself. The hair loses its gloss 
and soon falls out in large bunches, bringing the scabs 
with it. Occasionally a pustular Syphilide in the scalp 
takes on a peculiar appearance. Either by extension of 
a single sore, or by the coalescence of several, the pus- 
tules attain the size of a quarter or a half dollar. The 
base proliferates and forms a mulberry-shaped tumor 
which may attain the size of a pigeon's egg (frambesia 
syphilitica), and the surface is covered with a dirty brown 
scab. The proliferated tissues bleed at the slightest touch 



22 SYPHILIS. 

and cause the patient much pain ; they are very refractory 
to treatment (Plates 44, 45). Scars form after the pus- 
tules heal, and bald spots remain corresponding in extent 
to the areas destroyed by the process. 

Diseases affecting the Palms of the Hands, the Soles 
of the Feet, the Fingers, and the Toes. 

Psoriasis syphilitica palmaris et plantaris is 

the commonest form of syphilitic disease in the palms 
of the hands and the soles of the feet. It is a papular 
Syphilide, which, however, appears much later than the 
exanthemata on other parts of the integument and pre- 
sents some essential differences in its course. As the 
epidermis under which the papules form is very thick, 
it is often four months after the infection before they 
appear on the surface — long enough for the entire course 
of a papular form on the rest of the integument. In some 
cases psoriasis palmaris et plantaris appears much later, 
even several years after infection, the patient meanwhile 
being entirely free from any morbid symptoms. Lastly, 
the disease in many cases offers an obstinate resistance to 
every kind of treatment and persists after gummatous 
processes and disease in individual organs have already 
put in their appearance. 

The papules themselves consist of small nodules vary- 
ing in size from the head of a pin to a pea, and covered 
with a tough, horny epidermis. Often the patients do 
not become aware of them until they invade the region 
of the phalanges, and thus produce pain either by direct 
pressure or when the patient grasps any hard substance. 
Sometimes they appear in the form of flat, livid spots 
with horny, dirty yellow epidermis in the center ; the 
skin finally cracks and comes off in scales. In rare cases 
the papules attain a large size ; more frequently a number 
of them are crowded closely together, or even coalesce. 
The skin presents the appearance of infiltration, the 
horny epidermis cracks, and in a short time, especially 



SECONDARY SYPHILIS. 23 

if the skin is hard and thick, painful fissures develop at 
the flexures which seriously interfere with the use of 
the hands and feet, or even render them entirely helpless. 

If papules are formed between two fingers or between 
two toes, the epidermis rapidly becomes macerated, an 
open sore results, and the fingers or toes, as the case may 
be, become swollen and livid, and their proximal extrem- 
ities cut by radiating ulcers. Later the entire hand or 
foot becomes swollen and exceedingly painful, and, if 
the proper treatment is not administered in time, grave 
lymphangitis may develop. 

If the papular infiltration attacks the matrix or mar- 
gins of the nails, their nutrition becomes seriously im- 
paired and syphilitic onychia or paronychia results. 
The distal phalanx becomes more or less swollen ; the nail 
itself very horny, dry, and brittle, resembling a claw in 
shape ; gradually it separates from the underlying tissue, 
the color changes to a dirty yellow or brown, the nail is 
pushed more and more forward and finally cast off en- 
tirely. If, as frequently happens, the process is accom- 
panied by suppuration at the margin, the patient suffers 
intense pain, and the afflicted member becomes useless, 
especially as several fingers or toes are usually affected 
at the same time or in rapid succession (Plates 30, 31a, 
31b, 32). 

The disease usually lasts several months. The nails 
grow again, as a rule, though it may be only after the 
lapse of six months or even a longer time. 

Secondary Syphilitic Phenomena in the Genitalia and 
about the Anus. 

In the secondary period the genital and anal regions 
are most frequently the seat of grave phenomena which 
claim our attentive consideration on account of the regu- 
larity with which they appear, their tendency to recur, the 
great danger of infection, the variety of different forms, 
and, lastly, on account of the important role which the 



M SYPHILIS. 

resulting alterations play in the diagnosis of visceral dis- 
ease in later stages. 

It is generally assumed that the tissues for some dis- 
tance around an initial lesion are completely impregnated 
with the syphilitic virus, and are therefore in a state of 
irritation which affords a fertile soil for the production 
of new forms. This is especially true of the genitals, 
where the irritation is increased by the secretions, by 
sweat, and by want of cleanliness. Before the general 
integument becomes diseased, papules frequently appear 
at the edges of the labia majora in the female (espe- 
cially in chancre of the vaginal opening) and on the 
scrotum in the male. Many people pay no attention 
whatever to such phenomena, either because they feel no 
pain, or because they are naturally indolent and care- 
less, or attribute them to some other cause. Hence, rela- 
tively larger papular eruptions develop in these regions 
than on the rest of the body ; the surface soon becomes 
macerated and ulcers are formed, with the production of 
detritus, pus, or only a serolymphoid secretion, according 
to the kind of degeneration present. These materials con- 
tain the most virulent form of the poison and are the most 
frequent source of syphilitic infection. The closely packed 
papules are at first very shallow ; they soon run together 
and produce extensive ulcers, speckled on the surface 
and moderately infiltrated at the base, exuding a scanty 
secretion. 

Sometimes a diffuse infiltration surrounds the lymphat- 
ics in the affected area — for instance, the prepuce, the 
skin of the penis, the labia majora — and the above-men- 
tioned indurative edema develops. 

The ulceration in genital and anal Syphilide is rarely 
deep seated. As a rule, after a short duration — four to 
six weeks — the papules begin to grow upward from the 
base and often attain the size of a mulberry or a hazelnut. 
The proliferated masses are densely packed, raw on the 
surface, and present the appearance of proliferating 
venereal condylomata acuminata (also called venereal 



SECONDARY SYPHILIS. 25 

papillomata). Multiplying syphilitic papules (papulae 
luxuriantes) are distinguished from the latter by the 
enormous proliferation and infiltration of the base, which 
is slightly raised above the level of the skin, and the 
absence of the deep fissures which separate the individual 
venereal papillomata down to their bases. There are also 
some anatomical differences between the two processes, 
the luxuriating papular Syphilide being characterized by 
an abundant round-celled infiltration in the papillary 
layer of the skin, while the papilloma multiplies more in 
the epidermis. 

In the perineum, on the nates (PL 37), and in the 
glandular parts about the anus the appearance of papules 
is attended with the same conditions as in the genitalia. In 
the anal region peculiar formations sometimes develop 
on account of the anatomical relations of the parts. The 
folds become longer, hard, and infiltrated ; the intervals 
between them are marked by deep fissures which pene- 
trate into the aperture of the anus. These fissures either 
radiate from the center, or they may be placed crosswise, 
so that the infiltrated folds are partially loosened from 
their bases. The general appearance suggests a number 
of fresh nodules in process of formation. The condition 
is painful in itself, and becomes doubly so during defeca- 
tion, so that even the most indolent and careless individuals 
are led to seek professional advice. 

It remains to be said that such processes result in in- 
filtrates which penetrate deep into the skin, and, in spite of 
the most energetic treatment, often become the seat of new 
ulcerations. They are found by experience to constitute 
the most frequent source of syphilitic infection. It is not 
rare to see papular eruptions suddenly appear in the geni- 
talia and about the anus after many years, when no other 
symptoms are demonstrable in the rest of the body. Such 
an eruption frequently occurs in the course of pregnancy 
as a result of the venous stasis in the genitalia. In pros- 
titutes we have frequently seen single glistening, and later 
weeping papules of this kind appear in this region, when 



26 SYPHILIS. 

absolutely no other signs could be demonstrated in the 
rest of the body (Plates 33 to 39). 

Diseases of the Buccal Mucous Membrane. 

The mucous membrane of the mouth is almost always 
involved to a greater or less degree in the processes of 
the secondary period, besides being often the seat of 
primary lesions as a result of direct infection (Plates 8 to 

ii). 

Thus we often see papules on the mucous joa em brane 
of the lips and cheeks, especially if they are already 
in a state of irritation from sharp fragments of teeth, or 
from excessive use of tobacco or other irritants. These 
papules differ from those on the skin chiefly by their 
rapid ulceration. As we can readily understand, the dis- 
eased spot on the mucous membrane, poorly nourished 
through its base, soon becomes macerated ; the epithelium 
becomes cloudy and of a pale, whitish color ; as early as 
the second day the surface breaks down, and we have a 
shallow ulcer with infiltrated floor which bleeds very 
easily (Plates 40, 41a). 

Even more frequently than on the lips and cheeks we 
find papules on the pillars of the fauces, the tonsils, 
and the soft palate. They may be so numerous on the 
isthmus and in the throat as to simulate the clinical 
picture of croup or diphtheria. The diagnosis, however, 
is not difficult, since the condition is never accompanied 
by rise in temperature, the course is slow, and is fur- 
ther distinguished by the presence of other symptoms 
in the body. Disease of the tonsils occasionally gives 
rise to more or less grave functional disturbances. For, 
if they are severely attacked by the morbid process, they 
become much enlarged, the isthmus is narrowed, the 
patient's voice becomes nasal, and he suffers from exces- 
sive salivary flow and particularly from dysphagia. 
Sometimes the crypts break down and produce deep 
ulcers in the tonsils. 



SECONDARY SYPHILIS. 27 

If the papules invade parts of the mucous membrane 
much exposed to traction, as the lips, angles of the mouth, 
and the base of the tongue, deep, cleft-like wounds, pene- 
trating below the mucous membrane, are very apt to 
develop and cause the patient much discomfort. 

The gums are less frequently attacked by papules 
than the rest of the buccal mucous membrane. The gums 
appear swollen and infiltrated, and the ulceration at the 
edges of the gums often loosens the teeth in their sockets. 

In advanced cases of syphilis in the secondary period 
we occasionally meet with infiltrations in the buccal 
mucous membrane which are remarkable for their disin- 
clination to form ulcers. We have seen such a diifuse 
infiltration in the soft palate and uvula, which converted 
the soft, flexible pillars into a tough, glistening band of a 
dark-red color and elevated above the surrounding tissue. 
The infiltrations shrink and produce a distortion of the 
velum palati and a retraction of the uvula to one side or 
the other (PI. 42a). 

The tongue is very often the seat of secondary syph- 
ilitic disease, which presents itself in so many various 
forms that it well deserves our interest. As there is an 
undoubted relation between mechanical irritation of a 
part and localization of syphilis in it, we must not be 
surprised that the tongue rarely escapes in a syphilitic 
attack. 

As early as the papular stage individual papillse on the 
dorsum of the tongue become more prominent and form 
spots the size of a pea, covered with loose, whitish epithe- 
lium. Later the epithelium comes off and the spots are 
converted into glistening, flesh-colored patches, and, if 
the process of maceration and disintegration goes on, into 
dirty yellow ulcers, raised above the level of the skin. 
This is particularly apt to occur on the dorsum and at the 
edges of the tongue, which are often intensely irritated by 
sharp, decaying teeth or remnants of teeth ; the condition 
is very common in smokers and drinkers, especially if the 



28 SYPHILIS. 

care of the mouth is neglected. Such ulcers, of course, 
interfere greatly with speaking and eating. 

Next in order after disease of individual papillae we 
have a form which attacks larger areas on the surface of 
the tongue ; the affected areas are sharply circumscribed, 
glistening, and slightly infiltrated, with a tendency to 
form superficial fissures and sores. 

In a third variety, circular portions of the mucous 
membrane, as large as a penny, are converted into dense 
masses, distinct from the muscle and raised above the 
level of the tongue. The surface is marked by irregular 
furrows ; here and there single, hypertrophied papillae of 
a whitish color project from the surface. 

Another form, which is often overlooked, attacks the 
region of the circumvallate papillae or the adenoid tissue 
at the back of the tongue. In addition to the enlarged 
and infiltrated papillae themselves there are other irregular 
ulcers which may defy treatment of every kind for a long 
time. Healing is followed by contracted scars, often cov- 
ering large areas at the base of the tongue (PI. 41b). 

THE TERTIARY STAGE OF SYPHILIS. 

The late manifestations of syphilis mostly take the 
form of gummata, hence this stage of the disease is 
called the gummatous stage, or, to carry out the anal- 
ogy with the secondary, the tertiary stage. If these pro- 
cesses in the organism assume a malignant type and great 
destruction of tissue ensues, with the additional complica- 
tion of amyloid degeneration of internal organs, we have 
the condition of syphilitic cachexia, which Sigmund has 
designated the fourth stage of syphilis. 

The majority of syphilitic patients are fortunate enough 
to see their disease end with the symptoms of the second- 
ary stage. The cases are rare in which tertiary and 
secondary products are present at the same time. They 
constitute what we have already referred to as malig- 
nant or precocious syphilis. In these unfortunate indi- 



TERTIARY SYPHILIS. 29 

viduals the pustula major often appears as the initial 
eruption ; at the same time they are tormented by peri- 
osteal gummata (tophi), and before the end of six months 
destructive processes begin their work in the cavities of 
the mouth and nose. To make matters worse, the usual 
remedies fail to arrest the malignant process, so that the 
patient's life is often put in jeopardy. 

On the other hand, it frequently happens that the 
patient feels perfectly well for years after the completion 
of the secondary period, and is then suddenly reminded 
of his half-forgotten trouble by a renewed outbreak of 
morbid symptoms. The duration of this latent stage or 
intennission-periody during which the patient feels com- 
paratively well, varies greatly. In one case thirty-four 
years elapsed between the disappearance of the secondary, 
and the advent of the tertiary symptoms ; other observers 
put the duration of the intermission-period at from forty 
to fifty years. 

Within recent years many attempts have been made to 
ascertain why tertiary forms should appear at all in certain 
cases. Some attribute it to inadequate treatment or to 
the entire want of treatment during the secondary stage; 
others are of the opinion that a disposition to the develop- 
ment of gummata may be produced by privation, or by 
tuberculosis, malaria, and other diseases which tend to 
weaken the system. As yet, the controversy is still in 
the theoretical stage, and the physician will do well not 
to make any promises to the patient after the disappear- 
ance of the secondary symptoms. 

Many authorities assert that, in addition to a general 
disposition, an immediate cause is necessary to produce 
gummatous processes — for instance, a blow or other injury 
to a bone sparingly covered with soft parts, protracted 
excitement, alcoholic abuse, in the case of nervous dis- 
ease, etc. This view served as the basis for the theory of 
the connection between syphilis and irritation, although it 
cannot be said to hold true in every case. 

Many physicians lay down the universal rule that the 



30 SYPHILIS. 

secretions of tertiary products, since they are not adapted 
to the inoculation of syphilis, can never carry the syphil- 
itic contagion. We have already referred to this question 
in the introduction, and we again insist that the proposi- 
tion must be accepted with great caution, and that it cer- 
tainly does not hold in acute cases. 

The tertiary stage differs in many respects from the 
secondary, not only in the nature of the lesion itself 
(gumma), but also in the manner of its occurrence. 

The gumma is not preceded by general symptoms. 
Very often the patients are completely taken by sur- 
prise, and only begin to feel pain after the lesion has 
actually appeared ; the degree of pain and interference 
with movement depends on the duration and seat of the 
process, and may be very great. It is only in consequence 
of the pain and discomfort that the patients show emacia- 
tion and other signs of disease. 

Gummatous processes are further distinguished from 
secondary ones by the absence of symmetry in their dis- 
tribution or regularity in their order of appearance. They 
are usually found only on one side of the body-surface, or 
even in one particular spot, and they not only persist for a 
long time, but may even recur in the same place. Some- 
times the skin and mucous membranes are the seat of the 
first appearance of the gumma ; again, the bones or even 
internal organs. In severe cases the process may, how- 
ever, attack different parts of the body at the same time. 

Gummata really represent a kind of neoplasm consist- 
ing of granulation-tissue. The nodes are composed of 
an irregular accumulation of granulation -tissue, in which 
the cellular element predominates more or less and which 
is in process of conversion into connective tissue ; the 
normal tissue is crowded out and disappears entirely, or 
it becomes involved in the degeneration to which the 
syphilitic product itself falls a victim. At one stage of 
their development the tumors possess an elastic consist- 
ency, whence the name " rubber-tumor ; " tumors of 
longer standing may be more hard. 



TERTIARY SYPHILIS. 31 

The tendency to degenerate which characterizes 
all syphilitic products is shared by the gumma to a high 
degree. It is seen even in relatively recent gummata ; 
the process begins in the center of the node, destroying 
the structure of the tissue, while at the periphery some 
newly formed connective tissue, well supplied with blood- 
vessels, remains and gradually merges into the adjacent 
tissue. 

This characteristic property indicates the subsequent 
fate of the tumors. Gummata of subcutaneous and sub- 
mucous cellular tissue, and subperiosteal gummata, often 
undergo rapid mucoid degeneration. Gummata in the 
glandular organs, liver, testes, and in the brain or in the 
muscles undergo fatty metamorphosis, and we may find 
dry caseous masses enclosed in an area of newly formed 
connective tissue, as in a capsule, where it remains for 
years without undergoing any change. 

The gummata appear as individual nodes of varying 
magnitude ; not rarely, however, a fresh node develops 
at the periphery of a former infiltrate, so that we see 
some nodes undergoing ulceration while new ones are 
forming about their periphery (serpiginous character). 

We may also have multiple nodes appearing at the 
same time, or following each other at short intervals, so 
as to form groups of gummata ; as the densely crowded 
nodes degenerate, the tissue lying between them is de- 
stroyed, and elliptical or kidney-shaped tumors or ulcers 
are formed. 

Gumma of the Skin and Subcutaneous Cellular Tissue, 
The Gummatous Syphilide. 

Cutaneous gummata usually appear during the second 
year after infection, but may also occur after many years 
of comparative good health. The circumstances which 
we have referred to as predisposing the organism to ter- 
tiary forms have the same effect with regard to affections 
of the skin, and we must further bear in mind that the 



32 SYPHILIS. 

general integument of the body is more exposed to injury 
than are the other tissues and organs. 

An interesting fact, which has often been observed, is 
that gummata appear in places which were the seat of 
syphilitic products during the first and second periods ; 
this may be regarded as a local disposition due to the for- 
mer presence of the virus in the tissues. 

The gumma develops in the cutis or in the subcutaneous 
cellular tissue. The size of the nodes varies from a pea to 
a pigeon 's egg or larger. 

If the gumma is superficial, the upper layer of the 
skin becomes livid and shares directly in the further 
pathological changes of the gumma. 

If the nodes are seated more deeply, in the subcutane- 
ous tissue, the skin is not involved until later; as the 
node increases in size, the skin becomes infiltrated and 
more or less inflamed. In both cases the skin remains 
intact and recovers its normal color if the proper treat- 
ment is employed and the node is absorbed. 

If regeneration is too slow and the infiltrate becomes 
softened, the skin over it, which has meanwhile become 
very thin, also degenerates and an ulcer is formed. Ac- 
cording to the seat and size of the nodes, the ulcers are 
more or less superficial, and the edges overhanging or 
steep and abrupt. 

At first, the floor of the ulcer is covered with necrotic 
tissue ; soon, however, the scanty purulent secretion of 
the ulcer dries, and, with the extravasated blood, forms a 
dark-brown scab such as we have described in connection 
with pustulous ulcers of the skin. If properly treated, 
the ulcer soon cleanses itself and healthy granulation- 
tissue is formed. Scar-formation begins at the periphery 
of the wound, and a flat scar eventually remains. Grad- 
ually the rest of the infiltrate disappears ; the scar, which 
was livid at first, becomes white, and there is little dis- 
figurement. 

If several nodes develop at once and undergo rapid 
disintegration, large sinuous ulcers result. If the process 



TERTIARY SYPHILIS. 33 

continues and a new infiltrate is formed at the periphery, 
the ulcer becomes flattened on one side, but extends its 
limits on the other by fresh decay of the infiltrate, and we 
thus get Serpiginous ulcers, semicircular or reniform in 
shape, with scar-formation at the center and ulceration at 
the freshly infiltrated periphery. If degeneration is very 
rapid, either on account of the reduced condition of the 
patient or of unfavorable local conditions, the tissue- 
destruction is very great and the ulcers may attain the 
most alarming dimensions. Thus we have seen the skin 
of the entire lower surface of the thigh destroyed by ser- 
piginous gummata. 

Under unfavorable conditions the products of tertiary 
syphilis, even more than those of the primary and sec- 
ondary stages, are liable to gangrene. A tightly fitting 
garment pressing on the gummatous infiltrate often suf- 
fices to produce gangrene in an entire group of gum- 
mata ; general nutritive disturbances may bring about the 
same result. I remember a case in which a " starving cure " 
(dry rolls) caused the appearance of dry gangrenous scabs 
in eight different places on the body. After the scabs had 
come away, shallow wounds remained which showed 
scarcely a trace of the nodular character of the gumma. 

As to the nature of the scabs which form over gumma- 
tous ulcers, it may be said that simple ulcers with mod- 
erate secretion are covered with a scab consisting of a 
single layer; if the secretion is more abundant and the 
ulcer more extensive, the scab consists of several strata 
resembling an oyster-shell, like those described in the 
pustular Syphilide — the so-called rupia of older writers. 

The gummatous processes of the skin and subcutane- 
ous cellular tissue are not confined to these structures ; 
they often penetrate more deeply and involve the under- 
lying muscles, bones, and joints (see PL 55). Myositis, 
caries of the bones, and even necrosis not infrequently 
accompany an advanced gummatous process, so that the 
disease becomes more dangerous, and worse consequences 
result. The tissues may be injured directly by the spread- 

3 



34 SYPHILIS. 

ing gummata, or the resulting scars may be so extensive 
as to produce deformities or even destroy the movability 
of the limbs. In some cases the scars swell and pro- 
liferate, forming shapeless wheals (keloids) which may be 
present on the skin side by side with gummatous sores. 

Before leaving the subject of gummatous affections of 
the skin, of which there are such countless varieties, pre- 
senting ever- vary ing pictures, we would mention a mas- 
sive infiltration, one of the later forms of syphilis, which 
we prefer to designate diffuse hypertrophic syphil- 
oma or syphilitic leontiasis instead of syphilitic 
lupus. This form only appears long after the completion 
of the secondary stage. It develops slowly, and is dis- 
tinguished from the simple gummatous forms by its per- 
sisting for a long time without undergoing any marked 
change. It occurs in the form of hard, plate-like infil- 
trates on the lips, nose, and tongue. The infiltrate occu- 
pies the entire thickness of the parts mentioned, which 
eventually become quite immovable. The surface shows 
slight ulceration in places, but the process never attains 
the same depth and lateral extension as in the case 
of gummata. In every instance energetic antisyphilitic 
treatment is followed by absorption and healing of the 
sores; but for years afterward the site of the disease 
is marked by a moderate thickening of the connective 
tissue. 

Syphilis of the Motor Apparatus. 

As we have already remarked, the gummatous disease 
of the skin and subcutaneous tissue occasionally spreads 
to the underlying bones and muscles ; bones which have 
but a thin covering are chiefly affected, as the anterior 
aspect of the tibia, the cranium, sternum, clavicle, ulna, 
etc. (see Plates 52a, 55). 

The skin is naturally thin over these bones, and, if 
gummata develop, the bones very soon become involved, 
the periosteum is destroyed almost as fast as the skin 



TERTIARY SYPHILIS. 35 

it-self, and the bones are left entirely exposed. If the 
proper treatment is employed, the patients may escape 
with a slight granular exfoliation of the bone ; if, how- 
ever, the tissue-destruction is extensive, and large portions 
of the bone are exposed, caries usually sets in and the 
bone is more or less completely destroyed. The bones 
which we have enumerated — including, perhaps, the ribs 
— often become the seat of spontaneous periostitis. Pain- 
ful, slightly raised patches appear over the bone and increase 
steadily in size ; unless the process is arrested by the proper 
treatment, the skin becomes inflamed, and soft ulcers (tophi) 
are formed which rupture toward the surface and discharge 
a mucous secretion. 

Gummata proceeding from the skin, and involving the 
periosteum secondarily, find their analogue in a similar 
affection of the mucous membrane and the thin bones 
lying beneath it. The palate and the septum of the 
nose are chiefly affected ; the periosteum is destroyed by 
the ulceration in a few days, and the bones are laid bare 
and fall victims to caries and necrosis. 

So-called fibrous gummata frequently spring from the 
periosteum ; these gummatous tumors do not undergo the 
retrogressive metamorphosis and rapid decay which we 
have described ; they are hard and dense in structure, and 
embedded in a depression in the surface of the bone as in 
a niche. They yield to appropriate treatment by under- 
going absorption, but they constitute a serious disease 
on account of their origin, duration, and the amount of 
destruction they cause in the bone. The surrounding 
portions of the bone become thickened and sclerosed. 
Such slightly raised hyperplasia? are seen after periosteal 
processes of long standing in the flat bones of the skull, 
the anterior aspect of the tibia, etc. 

Another form of gummatous disease of the bones, both 
long and flat, is osteomyelitis ; in the long bones the 
process starts in the marrow, in the flat bones from the 
spongv substance, or from the diploe in the case of the 
skull." 



36 SYPHILIS. 

The patients complain of boring pain, which usually 
comes on at night, a long time before any enlargement 
of the bone is noticeable. I am reminded in this con- 
nection of a very instructive case of pneumonia, in which 
gummata were found in several of the long bones at the 
autopsy (osteomyelitis gummosa). 

The disease can undoubtedly exist for some time with- 
out producing any noticeable alterations, until finally the 
dense shell of the bone becomes enlarged or a central 
necrosis develops. The bones of syphilitic patients 
sometimes show a tendency to fracture from the most 
trivial causes ; such cases are usually characterized by 
great shortening of the bone and disinclination to unite 
(sjjontaneous fracture in gummatous osteomyelitis). 

In all such cases, whether they originate in a perios- 
titis or in an osteomyelitis, if the bone is macerated, the 
center is found to be rarefied, while the substance in the 
periphery is increased in density. 

If large portions of the periosteum are destroyed, or 
if several gummata exist side by side in the marrow, so 
that a large part of the bone is deprived of its nutrition, 
necrosis sets in and the affected portions of the bone are 
cast off as sequestra. If the soft parts become inflamed 
and ulcerate, caries also results. 

Smaller long bones like the clavicle and the phalanges 
become rarefied by extensive gummatous infiltrations and 
produce the condition known as Spina ventosa. It has 
been observed in the clavicle and also in the phalanges 
after syphilitic dactylitis. 

Joints. — The synovial membranes of joints suffer in 
the same way as the periosteum, especially in the painful 
swellings of the joints which often occur in the early 
stages of syphilis (syphilitic arthromeningitis). 
Several large joints may become swollen, presenting the 
picture of articular rheumatism, and the diagnosis may 
be obscured by the exudation into the cavities of the 
joint, by the pain, and by the fever which is occasionally 
present. The condition is distinguished from rheumatism 



TERTIARY SYPHILIS. 37 

by the remittent type of the fever, the accompanying 
phenomena in the skin and mucous membranes, and by 
the shorter duration, especially if an ti syphilitic measures 
are employed. 

The prognosis in these acute forms of synovitis is fav- 
orable ; if they are neglected, however, or if a cold-water 
treatment is resorted to, ankylosis results ; there may even 
be crepitation, showing that erosion has begun in the car- 
tilaginous investment. 

But the syphilitic affections of the tertiary period are 
much more important than the disease we have just men- 
tioned ; grave alterations in the affected joint are almost 
invariably the result. We refer to gummatous disease of 
the bones or of the epiphyses, which have involved the 
joint, and peri-articular gummatous processes involving 
the fibrous capsules and ligaments, which have extended 
to the synovial membranes. Such articular cavities con- 
tain little serous exudation and are filled with adhesions, 
villous excrescences, and partially detached fragments of 
gummatous synovial membrane. 

The usual outcome in grave cases of syphilitic joint- 
disease is fibrous ankylosis, even if the syphilitic pro- 
cess is peri-articular. More rarely peri-articular gum- 
mata rupture toward the surface, and continue to ulcerate 
until they break through to the articular cavity and set 
up a purulent articular inflammation. Speedy surgical 
interference becomes necessary in such cases, as anti- 
syphilitic treatment is found to be useless. 

Muscles. — The muscles also appear to be attacked 
early in the course of syphilis by rheumatic pains. But 
both the primary and secondary forms usually disappear 
of their own accord and leave no permanent conse- 
quences. 

When gummatous disease of the skin and subcutaneous 
tissue penetrates to the muscles, the condition is more 
serious. 

The muscle may also become the primary seat of a 
gummatous infiltration (myositis gummosa). The 



38 SYPHILIS. 

muscular gummata may attain a considerable size, as 
large as a hen's egg, and the course and location are 
sometimes such as to cause them to be mistaken for 
tumors, especially sarcomas. The disease begins with a 
round-celled infiltration, starting in the perimysium and 
those layers of the connective tissue which still contain 
blood-vessels ; large portions of the perimysium become 
involved, and the transverse marking of the muscle-sub- 
stance itself is gradually lost. 

If such a gumma ulcerates, the muscle-substance may 
undergo necrosis and decay. As a rule, however, muscu- 
lar gummata undergo fatty degeneration, and a cheesy 
mass of rather dense connective tissue becomes encapsuled. 
After the necrosed tissue has been cast off or absorbed, 
an extensive, fibrous scar, composed of the connective 
tissue which surrounds the gummata in large masses, 
remains, which destroys the function of any muscles that 
may be still intact, so that the extremities invariably be- 
come disabled (PL 55). 

The infiltrative process frequently involves the ten- 
dons, especially the point of union with the muscle. All 
the tendons in the body are liable to the disease ; we have 
observed it particularly in the tendo Achillis and in the 
ligamentum patellse. 

The sheaths of the tendons are also occasionally 
the seat of an extensive gummatous hyperplasia (PL 52). 
After a long time the infiltrate finally comes away spon- 
taneously, but it is best to assist the process by surgical 
interference. 

Syphilis of the Lymphatic Apparatus. 

This heading includes diseases of the lymphatic glands, 
the tonsils, the follicles in the isthmus and in the throat, 
the spleen, the thyroid gland, and the suprarenal cap- 
sules. 

The characteristic glandular swelling of the primary 
stage finds its analogue in the general glandular enlarge- 



TERTIARY SYPHILIS. 39 

ment which occurs when the entire organism has become 
infected. It often makes its appearance before the skin- 
symptoms, but is sure to become aggravated if there is 
secondary ulceration in the skin and mucous membranes. 
In general, the glands are found to be more enlarged in 
scrofulous individuals and in those who have been weak- 
ened by disease. Swollen lymph-glands are often found 
in parts of the body (as the side of the thorax) where no 
glands can be felt normally. In the secondary period we 
can usually feel the inguinal glands, the cervical glands — 
from the mastoid process along the sternomastoid as far 
as the supraclavicular fossa — the axillary glands under the 
anterior margin of the pectoralis, the glands of the elbow 
over the internal condyle, etc. In autopsies on syphilitic 
subjects we have also found the internal glands swollen. 
The enlargement develops slowly and gives rise to elon- 
gated, spindle-shaped, hard nodes, although sometimes 
the spherical shape is retained. The glands shrink to 
their minimum with proper treatment. At first the 
glands appear reddish-brown in cross-section ; later, the 
hilus becomes filled with connective tissue and sometimes 
with large masses of adipose tissue, so that the cortical 
substance of the gland is much reduced in thickness. 

We have frequently observed glandular enlargement in 
the tertiary period. It is spontaneous and attains the 
size of a pigeon's or a hen's egg ; it disappears if potas- 
sium iodid is given, and recurs either in the same or in 
other groups of glands. Glandular disease sometimes 
coexists with gummatous swellings in the skin ; if the 
gummata are undergoing suppuration, they frequently give 
rise to glandular swelling (PI. 54). Glandular swelling 
is not always directly associated with cutaneous gummata, 
and must therefore be regarded as a special disease, 
since we often observe gummata in the skin and subcu- 
taneous tissue without any glandular swelling whatever. 

These gummatous processes in the glands may lead to 
caseous degeneration, and the cheesy masses may remain 
encapsuled for a long time. The process may, however, 



40 SYPHILIS. 

start in the glands and involve the skin secondarily, pro- 
ducing inflammation and finally suppuration and necrosis ; 
a typical case of this kind is shown in PL 53. In time 
the gland itself undergoes exfoliation (PI. 54), and a scar 
results. 

Spleen. — The spleen does not necessarily become 
swollen during the acute stage in every case of syphilis. 
But in a large number of cases, especially those in which 
the eruptive stage is complicated with chloranemia, a splenic 
enlargement can be demonstrated by palpation and per- 
cussion. It disappears when antisyphilitic remedies are 
given, just like the exanthemata of the secondary period. 
More rarely the organ remains indurated, the splenic pulp 
becoming harder and dryer ; the connective tissue of the 
trabecule and capsule becomes thickened, and the latter 
may be attached to neighboring tissues by adhesions. 
These splenic tumors mostly occur in conjunction with 
disease of the liver, stomach, intestine, and kidneys. 

Gummatous neoplasms have been observed as nodes of 
varying size in the interior of the organ, or more fre- 
quently beneath the capsule. They usually undergo 
fatty or cheesy degeneration, and can probably remain 
encapsuled within the spleen as a dry mass for a long 
time. 

This circumscribed form of splenitis cannot be dis- 
tinguished during life from the indurative diffuse variety 
which has been described. Anatomically such fatty or 
cheesy foci closely resemble infarcts ; it is often difficult 
to distinguish them from caseous, solitary tubercles. 
Sometimes a similar localized degeneration of the paren- 
chyma is produced by a syphilitic endarteritis. 

The spleen is more frequently the seat of amyloid 
degeneration than other internal organs in those who 
have died of syphilitic marasmus ; often we find amyloid 
disease in the spleen alone, the other organs being entirely 
free, or showing only traces of it. 

Gummata have also been observed in the thyroid 
gland and in the suprarenal bodies ; they are, how- 



TERTIARY SYPHILIS. 41 

ever, extremely rare, and have so far only been found 
accidentally. 

Syphilis of the Digestive Tract. 

Oral Cavity. — We have seen that the mucous mem- 
brane of the oral cavity is almost always involved during 
the secondary period. Papules, ulcers, and fissures are 
constantly found. The alterations which are produced 
in the tertiary stage are known as syphilitic pachydermia, 
or psoriasis mucosae oris; they occur in the mucous mem- 
brane of the tongue, the cheeks, especially opposite the 
teeth, and in several other localities. The characteristic 
sign is a thickening of the mucous membrane, with the 
formation of whitish patches, consisting of several layers 
of proliferated epithelium almost as hard and horny as 
epidermis. Other irritants besides syphilis have a share 
in the production of these patches, such as mechanical 
irritation by rough projections, sharp or decayed teeth, 
tobacco-chewing, smoking, and alcohol. The condition 
is incurable, and is very distressing to the patient on 
account of the tendency to form open sores ; the patches 
are extremely vulnerable, and possess absolutely no elas- 
ticity, so that a morsel of hard food suffices to make an 
abrasion (Plates 41b, 42b). Rarely, submucous gummata 
form under these whitish, epithelial layers ; much more 
frequently epithel iomata develop. 

Gummata in the oral cavity proceed from the submu- 
cosa, but they invade the mucous membrane so rapidly 
that it is very hard to determine whether they really 
sprang from the mucous membrane or from the sub- 
mucosa. They are usually found on the tongue, the 
palate, the isthmus of the fauces, and the nasopharyn- 
geal cavity. 

The Tongue. — There is scarcely an organ in which 
syphilis deposits so many and such various pathological 
products as in the tongue. The later stages of secondary 
syphilis are often marked by papular eruptions and ulcer- 
ation along the margin of the tongue and by extensive 



42 SYPHILIS. 

infiltration on the surface. Among the tertiary forms we 
count alterations of the surface, so-called psoriasis or leu- 
hoplasia of the tongue. We may also mention smooth 
atrophy of the root of the tongue [atrophia Iwvis baseos 
linguce), which, like psoriasis, is a persistent alteration 
and assumes a diagnostic significance in doubtful cases 
of syphilitic disease of internal organs. The process 
must not be confounded with cicatricial formations in 
this region, to which we have referred among the sec- 
ondary aifections. The atrophy develops without the 
patient's knowledge, probably in consequence of the 
lymphatic apparatus becoming involved, and corresponds 
to similar conditions in other tissues in syphilitic disease, 
as, for instance, atrophy of the heart-muscle. 1 

The development of a gumma in the tongue is a more 
frequent event. The gumma starts in the submucosa, 
and rapidly destroys the mucous membrane ; but it soon 
heals and leaves a scar, if properly treated. If a large 
gumma, or several smaller ones placed close together, 
develop in the submucous and muscular tissue, the tongue 
becomes greatly swollen, and, if the growth cannot be 
arrested, the swelling soon softens. The mucous mem- 
brane is destroyed and a reddish-brown mass is dis- 
charged. The cavity which remains is often quite deep, 
and shaped like a fissure ; its floor of a whitish color 
and covered with necrotic tissue. The tumors or ulcers 
are exceedingly painful and often prevent the patients 
from chewing and speaking, so that they soon become 
reduced in weight and strength. 

If the gummata persist a long time, or recur frequently, 
they may give rise to epitheliomata. It is often difficult, 
on account of the cachectic appearance of the patient, to 
decide if he is suffering from a gumma or from a neo- 
plasm. But carcinoma can be distinguished from a 
gumma by the lancinating pain, the condition of the 
glands, and, finally, by the failure of antisyphilitic rem- 
edies, so that the diagnosis is soon cleared up (PI. 57). 

1 See Nothnagels Pathology ; Kraus 1 s Diseases of the Oral Cavity. 



TERTIARY SYPHILIS. 43 

Gummata in the tongue leave cicatricial contractions which 
may interfere materially with the use of the member and 
lead to injury and recurrence of the gumma, sometimes 
even to the development of an epithelial cancer. 

The base of the tongue, the significance of which has 
already been referred to, is often the seat of gummatous 
neoplasms. They form in the adenoid tissue and produce 
ulcers and infiltrations which at first cause the patient no 
discomfort and therefore often escape detection. Unless 
the ulceration persists for a long time, the patients are 
not likely to have themselves examined. Palpation with 
the finger is as important in the diagnosis as inspection by 
means of the laryngeal mirror. The differential diagnosis 
from tuberculous ulcers and degenerated epitheliomata is 
undeniably difficult, and is based solely on the presence 
of other syphilitic signs and on the result of treatment. 

The junction of the hard with the soft palate is a favor- 
ite seat of gummatous neoplasms, distinguished from 
all others by their rapid decay ; before the patient has 
become aware of the disease, sometimes in a single 
night, a perforating ulcer develops. If the proper 
treatment is applied immediately, it may be possible 
to arrest the process and close the perforation, or at 
least to save a large part of the soft palate, so that the 
perforation can be closed by operative means after the 
ulceration has healed. But if the patient neglects to seek 
medical assistance, disintegration progresses rapidly, and 
after one or two weeks but a few shreds remain of the 
edge of the soft palate, from which hangs the infiltrated 
uvula. If these last remaining shreds tear through, the 
swollen uvula may be sucked into the air-tube and cause 
symptoms of asphyxia, so that it is best under such cir- 
cumstances to remove it. The mildest result of such a 
destruction of the palate is a cicatricial distortion of the 
isthmus of the fauces ; usually the arches are also in- 
volved in the degeneration. 

Gummata in the hard palate undergo decay just as 
rapidly, whether they arise from the submucosa or from 



44 SYPHILTS. 

the periosteum, and a perforation soon follows. The bone 
itself is attacked by caries, and in a short time a large 
sequestrum is detached, or the bone gradually crumbles 
and the detritus is discharged. A communication is 
established between the oral cavity and the posterior 
nares, which causes the patient much distress even after 
the formation of a scar, as the taking of liquid and soft 
food, as well as speaking, becomes impossible. Some 
patients remedy the trouble by means of tampons, but 
it is better to close the opening with a rubber plate, or, 
if the loss of substance has not been too great, by oper- 
ative means (Plates 56a, 56b). 

Gummatous disease is sometimes primary in the pos- 
terior wall of the pharynx, starting in the pharyn- 
geal tonsils, but it is more frequently secondary to disease 
in the nares or in the isthmus of the fauces. In an in- 
credibly short time the mucous membrane is converted 
into a large ulcer by the rapid spread of the destructive 
process, and the pharyngeonasal cavity is occluded pos- 
teriorly ; the destruction may extend to the periosteum 
and even to the turbinate bones (PL 56b). 

The resulting deformities depend, of course, on the 
degree of destruction. 

Even in the event of a cure certain deformities remain, 
depending upon the degree of tissue-destruction. The 
communication between the nose and throat is partially or 
completely cut off" by cicatricial contraction of the remains 
of the soft palate and of the pillars of the fauces. This 
has the effect of drawing the base of the tongue against 
the posterior wall of the pharynx, although a small open- 
ing may still maintain some communication with the esoph- 
agus and the larynx. Swallowing becomes so difficult that 
operative measures must sometimes be resorted to. Respira- 
tion is also impaired when the nasopharyngeal cavity is 
closed, as the patient is forced to breathe through the nose. 
This gives rise to laryngeal troubles, bronchial catarrh, and 
deeper processes which interfere with the respiration even 
more seriously. 



TERTIARY SYPHILIS. 45 

The ear is seriously affected by ulcerations in the 
pharynx ; the orifices of the Eustachian tubes are de- 
stroyed, delicacy of hearing is lost, and the patient 
suffers severe stabbing-pains. If the disease attacks the 
middle ear, grave lesions of the organ of hearing may 
result. 

The mucous membrane of the cheeks and lips 
and the gums are least frequently the seat of gumma- 
tous ulcers. If gummata and infiltrations do appear, 
they are usually situated on the lips, along the alveolar 
border (PI. 41a). Such ulcers do not differ materially 
from those we have described. They may assume diag- 
nostic importance in differentiation from tuberculous 
destruction of the mucous membrane or from epithelial 
cancer. In this connection it may be briefly mentioned 
that tuberculous nodules are very often seen at the pe- 
riphery of tuberculous ulcers, and that the floor never 
possesses the enormous infiltration which is characteristic 
of syphilis ; moreover, tubercular disease is rarely pri- 
mary in this situation ; we usually find at the same time 
advanced disease of the respiratory tract. 

The course of epithelial cancer is, generally speaking, 
slower than that of syphilitic processes, especially gum- 
matous infiltrations of the mucous membranes. In 
syphilis the submaxillary glands rarely become swollen, 
while they are always involved in cancer after it has per- 
sisted some time. Lastly, the diagnosis can be confirmed 
by means of the therapeutic measures which have been 
referred to. 

The salivary glands have occasionally been observed 
to become diseased in syphilis. 

Esophagus. — Syphilitic disease of the esophagus is 
usually diagnosed at the autopsy. The esophagus is never 
attacked primarily, but becomes secondarily involved in 
disease of the mediastinal glands and of the pharynx. 
Gummata in the mediastinal glands break through the 
wall of the esophagus, the mucous membrane is destroyed, 
and constricting scars result. 



46 SYPHILIS. 

Stomach. — Acute or subacute gastric catarrh occur- 
ring in the early stage is very rarely the direct result of 
syphilis. It may possibly be considered so in cases 
where it forms a sequel to existing syphilitic disease of 
the liver or kidneys. 

Ulcers consisting of gummatous infiltration of the sub- 
mucosa occur in the stomach as the direct products of 
syphilis. They are often discovered at the autopsy, 
usually in the region of the pylorus and the lesser curva- 
ture, but occasionally also at the cardiac extremity ; the 
infiltration develops in the submucosa and spreads to the 
mucous and also to the serous coats of the stomach. In 
addition to ulcerations, gummatous infiltrates and scar- 
formation have been found, so that it is fair to conclude 
that cicatrization of gummatous ulcers in the stomach is 
possible. 

In rare instances we find ulcers due to syphilitic arte- 
ritis of the gastric vessels ; they resemble the round gas- 
tric ulcer both in their clinical characters and in their 
anatomical appearance. 

Intestine. — Acute intestinal catarrh, or chronic ente- 
ritis, occurring in constitutional syphilis, cannot be diag- 
nosed in vivo ; they not infrequently accompany syphilitic 
disease of the liver, such as amyloid degeneration, and 
therefore do not belong to the syphilitic process. 

Ulcers, however, undoubtedly do occur in the intestine 
as the direct result of syphilis, but our knowledge of 
them is chiefly derived from accidental discoveries at the 
autopsy-table. They are usually multiple and localized 
in the small intestine, especially in the upper part. They 
usually develop from peculiarly rigid infiltrates, corre- 
sponding in position to the Peyer's patches, which pene- 
trate the mucous membrane and the submucous and mus- 
cular layers, as large as, or larger than, a dollar. The 
mucous membrane is destroyed and irregular cavities 
remain, almost circular in shape and placed transversely 
to the axis of the gut, with punched-out edges of mucous 
membrane and a rigid floor, either covered with a grayish 



TERTIARY SYPHILIS. 47 

secretion or consisting of scar-tissue. The serous coat 
hypertrophies, and false membranes are formed which 
may occlude portions of the intestine. The scars which 
remain are flat and cause some stenosis. 

In the large intestine the occurrence of grave dis- 
turbances is more common. Infiltrations of the anal folds 
and the fissures between them spread to the large intes- 
tine, or gummatous processes in the mucous membrane of 
the anus and in the perirectal tissues extend upward. 
The symptoms usually consist in the passing of muco- 
purulent matter, diarrhea, tenesmus, hemorrhages, and 
even prolapse of the diseased parts. 

After a time the connective tissue increases greatly 
and pronounced constriction of the lumen results. This 
is a grave condition, and the patient rapidly becomes re- 
duced by the intense pain, the fever, loss of blood, and 
excessive secretion in the bowel. Purulent periproctitis 
and even peritonitis may supervene and bring about the 
death of the patient. 

The I/iver. — Of all the internal organs the liver is 
the most frequent seat of the process. Whenever the 
internal organs are attacked by syphilis it is safe to 
assume that the liver is involved, even if .the disturb- 
ances in other organs are the most prominent symptoms. 
The liver may also be the only organ diseased. Two 
forms are distinguished : interstitial and gummatous hepa- 
titis. The two pathological alterations are nearly always 
associated ; sometimes only portions of the organ are in- 
volved, sometimes the entire liver. 

Hepatic gummata form larger or smaller nodes, usually 
about the size of a hazelnut, either single or disposed in 
groups so as to form tumors the size of a hen's egg. They 
are rather more common in the right lobe, and particularly 
affect the junction between the two lobes, under the sus- 
pensory ligament. They are usually found in a condition 
of necrosis or caseous degeneration, enclosed in strands of 
connective tissue of varying density which radiate more or 
less irregularly into the surrounding parenchyma, dividing 



48 SYPHILIS. 

the liver-substance Into irregular islands. The proliferat- 
ing gummatous granulation-tissue encroaches upon, and 
finally obliterates the liver-tissue, leaving only the smaller 
bile-ducts. The latter may be greatly hypertrophied. 
Gradually the cheesy masses are absorbed, the granula- 
tion-tissue partly disappears or becomes converted into 
fibrous connective tissue, deep, contracting scars appear 
on the surface, marking off whole sections of the organ — 
the hepar lobatum. If large numbers of gummata are 
massed in one situation or in one lobe, large areas or an 
entire lobe may disappear. If the gummatous process 
extends over the entire organ, there is a general increase 
in the connective tissue, subdividing the parenchyma into 
small islands — so-called syphilitic cirrhosis. It is charac- 
terized by an unequal distribution of the connective tissue, 
abundant at the seat of former gummata, less plentiful 
elsewhere. As the liver-tissue disappears, the parts that 
remain hypertrophy and regenerate, so that the islands of 
liver-tissue soon increase in size and produce lumpy ex- 
crescences on the surface, enlarged lobules on the cut sur- 
face, or enlargement of an entire lobe. Thus we have 
seen the left lobe hypertrophied to the normal size of the 
right, when the latter had become atrophied as a result of 
syphilitic disease. 

In addition, peritoneal adhesions and distortions of the 
organ or of the gall-bladder and larger bile-ducts occur, 
and, with the interference to the portal circulation caused 
by the tumors and the overgrowth of connective tissue, 
add to the many disturbances which we observe in the 
living subject. 

Pancreas. — Although the pancreas is very often dis- 
eased in the hereditary form of syphilis, the organ usually 
escapes in the acquired form in adults. Occasionally gum- 
matous disease and alterations produced by disease of the 
vessels have been observed, but the cases are extremely 
rare, and the condition cannot be determined in vivo ex- 
cept by inference, when gummatous processes are present 
in other situations at the same time. 



TERTIARY SYPHILIS. 49 

The Respiratory Tract. 

The Nasal Cavity. — In the secondary period the 
mucous membrane of the nasal cavity is less commonly 
affected than is that of the oral cavity. The late lesions, 
6n the contrary, are quite common and are of great prac- 
tical significance. The most frequent seat of gummatous 
ulcers is the septum, especially the junction between the 
cartilaginous and bony portions. It scarcely needs to be 
said that the periosteum and investing mucous membrane 
rapidly break down and ulcerate. Before long the cartil- 
age softens, the bone becomes carious, and perforation of 
the septum results. Such a perforation is sometimes dis- 
covered by the physician before the patient himself is 
aware of it. The secretion is purulent and mixed with 
blood, and has a most offensive odor ; often it dries in the 
nose and forms brownish crusts which conceal the floor 
of the ulcer and the necrotic portions of the bone. The 
necrosis spreads along the line of the bony septum to 
the hard palate and a perforation of the bony plate of the 
palate results. The adjacent bones, the superior maxil- 
lary, the ethmoid, the internal pterygoid plates of the 
sphenoid, and the lachrymal bones may also be involved. 

While ulceration and suppuration are going on, the 
sense of smell is entirely lost, and is seldom regained 
even if a cure is effected. Destruction of the cartilagin- 
ous septum results in the saddle-nose ; destruction of the 
vomer and of the nasal bones produces sinking of the 
entire nose. It is often possible to save the skin of the 
nose even when there has been extensive destruction 
within the nasal fossa, but in time it withers and shrinks 
to a shapeless stump, nor is any plastic operation possible. 
In badly neglected cases the entire nose, including the 
skin, may be destroyed. 

From the nasal fossae the ulceration spreads to the 
upper lip, the alaa of the nose, the lachrymal gland, the 
posterior nares, and even as far as the head of the 
pharynx. 



50 SYPHILIS. 

Even after the process has healed, there is danger of 
the scars in the nasal cavity reopening, and constant care 
is necessary to prevent a recurrence of the disease. 

In the larynx the mucous membrane early (in the 
secondary period) shows signs of the disease in the form 
of papules, ulcers, and vegetations. The appearance of 
gummata in this important organ in the tertiary period is 
of the most vital significance to the patient. They are 
counted among the dangerous forms of syphilis, as the 
rapid disintegration endangers the cartilages of the larynx, 
the epiglottis, and the muscles and vocal cords with the 
mucous membrane covering them. It is, therefore, of 
the greatest importance to warn the patient of his danger, 
so that he may subject himself to the necessary treatment 
as early as possible. In themselves the gummata do not 
differ from those found in other mucous membranes, 
being characterized by the same tendency to rapid de- 
generation. 

Infiltrations and ulcerations in the trachea and in the 
bronchi often follow syphilis of the larynx. The pro- 
cess may also begin in the mediastinum and involve these 
structures secondarily. The gravity of the symptoms 
depends on the extent and depth of the ulcerative pro- 
cess ; very troublesome after-effects may remain even 
after a cure is effected. 

I/ung- disease in acquired syphilis is one of the 
rarer occurrences, especially if we exclude the cases which 
result from obstinate disease of the larynx and trachea. 
Cicatricial hyperplasia of lung-tissue and peribronchitis, 
associated with gummata, have been observed at autopsies. 
I have never been able to convince myself of the correct- 
ness of these anatomical changes by my own experience. 
Glandular tumors in the mediastinum may exert pressure 
on the bronchi and produce peribronchitis by contiguity. 
If the parietal layer of the pleura or the viscera are in- 
volved, we may have periostitis or necrosis of the ribs, 
and adhesions. 



TERTIARY SYPHILIS. 51 

Syphilis of the Circulatory System. 

Although the doctrine of syphilitic disease of the organs 
of circulation is one of the more recent achievements of 
morbid anatomy, more and more facts are being daily 
collected to show that it has received too little attention 
in the consideration of syphilitic products. 

The heart presents many pathological alterations after 
syphilis. We distinguish three divisions : syphilitic 
changes in the smaller vessels of the heart, the products 
of syphilis in the pericardium and endocardium, and 
finally in the myocardium itself. Not to exceed unduly 
the limits of this sketch, we shall merely mention the 
most important alterations and the clinical phenomena to 
which they give rise. 1 

All the syphilitic affections of the heart that have been 
observed belong to the tertiary period ; those observed in 
the secondary period have no anatomical foundation and 
must be regarded as functional disturbances. 

Fibrous myocarditis is characterized by increase in the 
connective tissue and by the formation of wheals, and 
secondarily by atrophy and wasting of the muscle-sub- 
stance. It is found, in limited areas, distributed over the 
interventricular septum and in the walls of the ventricles 
and auricles. 

The gummata in the myocardium produce nodes of 
varying size, showing fatty or cheesy degeneration at the 
center and surrounded by layers of fibrous connective 
tissue. Like all gummata, they may remain in this con- 
dition for a long time, or they may break down and pro- 
duce more or less destruction and loosening of the papil- 
lary muscles and valves. 

Syphilitic endocarditis and pericarditis are usually but 
accompanying processes of disease of the myocardium. 

In making a diagnosis in vivo it is to be remembered 
that the syphilitic symptoms appear most frequently 

1 For further details on "Syphilis of the Heart," see Archiv, für 
Dermatologie und Syphilis, 93. 



5'J SYPHILIS. 

between the ages of thirty and forty, associated with, or 
following upon the later lesions of syphilis. At a more 
advanced age disease of the heart is usually due to athero- 
matous change or to rheumatic endocarditis, or to fatty or 
fibroid degeneration, as, for instance, in chronic alcohol- 
ism, so that the diagnosis is extremely difficult. It is to 
be remembered also that grave functional disturbances of 
the heart may be simulated by syphilitic products in the 
central nervous system, as, for instance, in the bulb. 

In disease of the heart-muscle manifesting itself in 
angina, palpitation, and severe dyspnea, it is easy to 
demonstrate the objective symptoms of dilatation, asys- 
toly, arrhythmia, cyanosis, and slight anasarca. Other pro- 
cesses in the region of the valves may produce the symp- 
toms of valvular insufficiency. Syphilitic endarteritis of 
one of the coronary arteries may give rise to the most 
intense symptoms of angina pectoris. For the benefit of 
the practitioner we repeat and emphasize the rule laid 
down by Semola : " If a patient, who has unquestionably 
had syphilis, presents himself with symptoms of a per- 
sistent arrhythmia, which refuse to yield to hygienic or 
pharmaceutical remedies, the physician must conclude 
that a syphilitic process exists, and must order specific 
treatment for the patient, even if at the time there are no 
symptoms which furnish ocular proof of the presence of 
constitutional syphilis." 

Most cases of heart-syphilis are discovered accident- 
ally at the autopsy. Death usually occurs rapidly and 
unexpectedly ; rarely death is preceded by exhaustion of 
the degenerated myocardium with symptoms of cardiac 
weakness. 

Although we are unable to diagnose syphilitic cardiac 
disease with certainty in the living subject, yet it is the 
duty of the physician, as stated in Semola's proposition 
quoted above, to fight the disease with iodids and even 
with mercury in doubtful cases, using the proper precau- 
tions, as the disease is always dangerous and almost certain 
to end fatally. 



TERTIARY SYPHILIS. 53 

In arteries of medium caliber Heubner has de- 
scribed a specific affection which proceeds chiefly from 
the greatly hypertrophied intima ; it is known as endar- 
teritis obliterans. All the layers are affected; in some 
cases cheesy degeneration develops and destroys the ad- 
ventitia and media, so that we are justified in speaking of 
gummatous arteritis. It occurs most frequently and in its 
most typical form in the arteries at the base of the brain ; 
it has, however, also been observed in the carotid, the 
popliteal, the renal, and the splenic arteries, and in periph- 
eral branches. The consequences are atrophy and 
necrosis of the organ (spleen) ; also encephalomalacia, 
to which we shall return later. 

The etiology of thickened valves and endo-aortitis is more 
obscure, as these structures are so frequently the seat of 
general atheromatous changes ; the same is true of the 
sequelae, especially of aneurysms, and we take occasion to 
emphasize the fact that aneurysms never form in the cere- 
bral cranial arteries in the typical form of the disease. 

The smallest arterial branches are sometimes found to 
be involved in the late forms of syphilis ; trophic disturb- 
ances and overgrowth of the connective tissue are the 
result. 

The veins are rarely the seat of syphilitic products, 
although gummata have been described in the jugular and 
in the sheath of the femoral. 

Syphilis of the Genito=urinary Apparatus. 

Kidney. — The observations of the last few years have 
shown to what extent the kidneys may be affected by the 
syphilitic process. The presence of albumin in the kid- 
neys of a syphilitic patient is not in itself enough to 
warrant a diagnosis of syphilitic disease of the kidneys. 
When mercury is given in the early stage of syphilis, the 
excretion of the mercury sets up an irritation in the kid- 
ney, and considerable quantities of albumin are found in 
the urine. Amyloid disease is found in the kidneys of 



54 SYPHILIS. 

cachectic individuals in the late stages of syphilis. These 
conditions make it difficult to determine whether the kid- 
neys are directly concerned in the syphilitic process. 
Even in syphilitic subjects a nephritis based on diffuse 
interstitial proliferation is considered to be sufficiently 
accounted for on anatomical grounds. Still, gummatous 
tumors have been found accidentally at autopsies. It is 
not likely, however, that their presence would even be 
suspected on clinical grounds, unless perhaps antisyphi- 
litic treatment were found to be followed by a good result 
in a case of violent renal symptoms pointing to degenera- 
tion of the parenchyma. 

In the bladder ulcers have often been observed which 
were thought to be due to syphilis. 

The testicles are much more frequently attacked by 
syphilis than is generally conceded. The disposition of 
this gland to specific disease may be explained on anatom- 
ical grounds, or by its liability to injury, or by previous 
disease. A slight infiltration, involving only the paren- 
chyma, is not demonstrable, as the alteration produced is 
not severe enough to cause the patient to consult a doctor. 
In a few instances I have been able to determine an in- 
duration in parts of one or the other testicle in men who 
were given to observe themselves anxiously, or who, being 
on the point of marrying, wished to be examined for 
possible remains of syphilitic disease, or even were 
reminded of a former attack of the disease by the birth 
of children with hereditary syphilis. In two cases which 
I had known before the disease occurred I was able to 
demonstrate an induration in the tail (globus minor) 
of the epididymis. 

Tavo forms are usually distinguished, fibrous and gum- 
matous orchitis. Both belong to the late forms and de- 
velop two years or more after the infection. 

Fibrous orchitis is more frequent and occurs earlier 
than the gummy form. It begins with an infiltration in 
the septum of the scrotum which spreads until it pene- 
trates the parenchyma ; the head (globus major) of the 






TERTIARY SYPHILIS. 55 

epididymis soon becomes involved. The patient feels no 
pain, only a seDse of increased weight and traction in the 
testicle ; the organ is found to be enlarged and harder 
than normal. If the process goes on, the body of the 
other testis is included in the tumor, which increases more 
and more in size. The patient complains of dragging 
pains as high up as the inguinal canal. 

With potassium-iodid treatment the symptoms often 
disappear within a few days ; but if the condition lasts, 
strands of connective tissue develop within the paren- 
chyma of the organ which atrophies in parts and becomes 
permanently indurated. 

Gummatous orchitis is distinguished by the appearance 
of a node, which gradually increases in size and becomes 
adherent to the investing membranes. The tumor is 
movable ; if it breaks down, it bursts toward the exterior, 
and a brownish material, consisting of detritus and thin, 
watery pus, is discharged. In cases of long standing 
there is usually more than one node ; the substance be- 
tween the nodes atrophies from pressure, and what remains 
becomes hard from overgrowth of the connective tissue. 

The tunica vaginalis propria also becomes involved in 
disease of the testis ; the writer has often seen it hyper- 
trophied and filled with a serous exudate. The scrotum 
may swell to the size of the fist or even the head of an 
infant ; the tumor is excessively tense, so that it is im- 
possible to distinguish the different parts of the organ by 
palpation. The closely adherent skin over a tumor of 
this kind may be destroyed in places. But, instead of a 
discharge of liquid products of degeneration, it is more 
common to have a solid mass of yellowish-white, fatty or 
cheesy material appear through the opening. If the pro- 
cess has gone as far as this, there is no hope of recovery, 
and amputation is the only relief. 

The penis, especially the glans, the coronary sulcus, 
and the prepuce, is often the seat of a gummatous pro- 
cess which must be distinguished not only from non- 
syphilitic tumors, but also from initial forms of syphilis 



56 SYPHILIS. 

(initial sclerosis). The gumma is much more prone to 
rapid decay than is the sclerosis ; hence it is very impor- 
tant to recognize a gumma as early as possible so as to 
begin the proper treatment at once. The condition of 
the inguinal glands is of vital significance, since they do 
not become swollen in gummatous disease ; in addition, 
anamnesis, duration, and course must be carefully taken 
into account. Gummata beginning in the coronary sul- 
cus are very prone to spread to the glans and often destroy 
it in a very short time. A gumma situated near the 
urethra is dangerous on account of its tendency to pene- 
trate into the corpus cavernosum. 

Gummata in the skin of the penis are equally danger- 
ous, not only because they destroy the skin and lead to 
external scar-formation, but chiefly because they spread 
to the corpus cavernosum. Occasionally the gumma 
starts in the corpus cavernosum itself. But in whatever 
manner the gumma may attack the corpus cavernosum, 
the infiltrate is sure to penetrate deeply and, after a cure 
by absorption has been eifected, to leave cicatricial con- 
tractions. The consequence is that the corpus cavernosum 
is imperfectly filled with blood, and there is usually a 
bend in the penis at this spot during erection, or, if the 
destruction has been very extensive, erection is incom- 
plete or even impossible. 

In the female genitals the vulva, and in more ad- 
vanced cases the vagina, are the most common seats of 
the process. Even under favorable conditions deformi- 
ties, cicatricial contractions, and stenoses result ; but if 
the process penetrates more deeply, it often produces per- 
forations into the rectum. Usually a thorough and pro- 
tracted course of treatment is necessary to arrest the 
ulceration, after which operative interference may be re- 
sorted to. If we at last succeed in arresting the process, the 
most we can hope to accomplish by an operation is to 
relieve to some extent the discomfort with which the con- 
dition is attended. 

Uterus. — Syphilis may invade the uterus by direct in- 



TERTIARY SYPHILIS. 57 

fection through the os (Plates 6a, 6b, 7). The resulting 
sclerosis is followed by extensive infiltration and over- 
growth of connective tissue at the cervix, Avhich may 
under certain conditions interfere with parturition. 

Papules may also appear on the mucous membrane of the 
vaginal orifice (PL 39). They are usually associated with 
papules on the external genitals and disappear with them 
under proper treatment. We may also mention the in- 
crease in size and density of the uterine tissue which is 
occasionally found in syphilitic parturient women. I 
have often seen labor interrupted by uterine hemorrhages, 
etc., in such cases, which usually ended in imperfect invo- 
lution of the uterus. 

Gummatous neoplasms have also been found in the 
uterine tissue, but they are no doubt extremely rare. 

Gummatous processes occur in the mammae in the 
later stages of syphilis ; they usually proceed from the 
subcutaneous tissue and, by spreading to the mammary 
gland, produce the picture of a mastitis (Plates 48a, 48b). 
The skin over these infiltrations in the tissue of the 
gland is usually destroyed, and deeper parts may be lost 
if the proper treatment is not at once resorted to. I 
have known masses as large as a pigeon's egg to be de- 
stroyed in rapidly spreading infiltrations and serpiginous 
ulcers of the skin and subcutaneous cellular tissue in 
neglected cases. Potassium iodid is a valuable remedy in 
disease of this organ, as it is in disease of the testicle ; its 
favorable influence on the process is manifest after a 
few days, and it may serve to clear up a doubtful diag- 
nosis. 

Syphilis of the Eye. 

The specialist in venereal diseases sees principally dis- 
eases of the orbits, the eyelids, the cornea, the sclerotic, 
and the iris, as deeper-lying diseases of the organ and 
paralyses are usually taken to the oculist. We shall, 
therefore, in accordance with the plan we have adopted, 
confine ourselves to a short review of these affections. 



58 SYPHILIS. 

Most forms of syphilis of the orbit occur as a peri- 
ostitis, either localized in the orbital margin from the be- 
ginning or extending from the frontal bone to the orbital 
margin. We distinguish two forms : productive and 
destructive periostitis, both due to a gummatous process. 
The hypertrophic forms often begin in the secondary 
period, and are to be distinguished from hyperostoses of 
the orbits, as they are attended with considerable deposi- 
tions on the orbital margin. The gumma attacks the 
skin as well as the bone, and may eventually perforate 
externally if it is not absorbed. The eyelid becomes 
edematous and remains immovable in a drooping position. 
If the levator palpebrse remains inactive for a long time, 
there is danger of the ptosis becoming permanent. If 
the destruction of the skin and eyelid is extensive, cica- 
tricial contractions, ectropion, and lagophthalmos result. 

The bones are more subject to gummy periostitis than 
to the hyperplastic form. A swelling in the periosteum 
and infiltration of the cellular tissue of the orbit may simu- 
late an orbital tumor, as the same symptoms occur in both 
conditions. The upper wall is most frequently attacked, 
more rarely the thin, internal Avail, the ethmoid bone. 
The disease is heralded by neuralgia and headache, becom- 
ing worse in the evening and at night; the pain is in- 
creased by touching the orbital margin. A characteristic 
symptom is dislocation of the globe, as it is a certain sign 
of infiltration in the periosteum and cellular tissue. If 
the periostitis is seated in front, the eyeball will be dis- 
placed laterally ; if at the bottom of the orbit, it will 
protrude forward (protrusio bulbi). Syphilitic tumors 
are large, so that there is usually exophthalmos in addi- 
tion to lateral displacement. A very characteristic phe- 
nomenon in syphilitic periostitis is interference with move- 
ment of the globe in one or more directions, even when 
the muscles are intact, showing that it is entirely due to 
dislocation of the globe. Eventually the muscles also 
become involved, and temporary or permanent loss of 
power results. If taken in time, the ulcers can often be 



TERTIARY SYPHILIS. 59 

cured ; but if the infiltrate liquefies, the ulcer breaks 
through the anterior surface, usually at the orbital mar- 
gin, even when the bone is still solid. If the periostitis 
runs on to necrosis, perforations into the nose and antrum 
of Highmore result; perforation into the cranium may 
produce a fatal meningitis. 

The skin of the eyelids is often attacked in pri- 
mary syphilitic disease. Later, papules may appear on 
the palpebral edges and on the conjunctivae. Gummata 
produce a plate-like infiltration, and the conjunctiva 
assumes the appearance of trachoma from the newly 
formed granulations. Syphilitic tarsitis, an affection of 
the cartilage of the eyelid, has also been observed in the 
gummatous stage (PI. 43b). Gummy processes in the 
lids may involve the conjunctiva and cause destruction or 
mutilation of the eyelid. 

Diseases of the cornea belong to hereditary syphilis ; 
they take the form of interstitial keratitis and are usually 
associated with diseases of the iris, the ciliary body, and 
the sclerotic. Gummata have been observed in the 
sclerotic, both primary and derived from the uveal tract, 
running on to degeneration and ulceration. 

Iritis is frequent in the secondary, but very rare in the 
tertiary, stage of syphilis. Several forms are distinguished. 
The mildest variety is probably serous iritis. It is char- 
acterized by photophobia, moderate ciliary congestion, a 
slight discoloration of the iris, and the appearance of a 
deposit on the posterior wall of the cornea. The pupil 
reacts to light, and the deposit often has the form of a 
triangle with its apex pointing upward. In the second 
form, plastic iritis, the ciliary congestion is greater, the 
discoloration of the iris more pronounced, its markings 
indistinct, the tissue more spongy, pupillary reaction 
almost absent, and the pupillary margin of the anterior 
lens-capsule held fast by adhesions. The pupil may even 
be covered by a newly formed membrane (pseudomem- 
brane). Deposits often appear on the posterior wall of 
the cornea. The aqueous humor is turbid, and on the 



60 SYPHILIS. 

floor of the anterior chamber there is sometimes found a 
hypopyon. In a third form, papular or condylomatous 
iritis, the ciliary margin of the iris is studded with small, 
miliary nodules, which spring from the tissue of the iris 
and have a reddish-yellow color (PL 43a). In this form the 
ciliary congestion and the posterior adhesions are more 
marked ; the other symptoms are the same as those of 
plastic iritis. Unless relief is speedily obtained, various 
troublesome conditions may result — adhesions, occlusion 
of the pupil, and other grave disturbances. 

We pass over the diseases of the ciliary body, the 
choroid, the vitreous body, the retina, and of the optic 
nerve, as they belong to the special province of ophthal- 
mology both as regards diagnosis and treatment. 

Syphilis of the Central Nervous System. 

Syphilis of the Brain. — Syphilis of the central 
nervous system manifests itself in such a multiplicity 
of forms and gives rise to such a vast number of symp- 
toms that it is difficult to distinguish it from other nervous 
diseases. There is hardly a symptom in the entire 
pathology of the nervous system that may not be pro- 
duced by syphilis. A diagnosis of syphilitic nervous 
disease must therefore be based on a definite history, or on 
the existence of other processes combined with the ner- 
vous lesion that are positively known to be specific in 
character. Generally speaking, syphilitic nervous diseases 
belong to the late forms of syphilis, the majority appear- 
ing from the fifth to the tenth year after the disease has 
been acquired. In order to get a general idea of this ex- 
tensive group of diseases we must bear in mind that the 
processes which eventually attack the nerve-substance, 
and either partially or wholly destroy it, may originate in 
various ways. Destructive processes in the bones extend 
to the dura and meninges and thence to the brain itself. 
Conversely, gummata in the dura produce pathological 
changes in the bone and in the meninges. Gummatous 



TERTIARY SYPHILIS. 61 

or chronic inflammatory processes may originate in the 
softer membranes, the arachnoid and the pia, and invade 
the brain secondarily. Lastly, arterial disease is the 
commonest cause of pathological alterations in the nerve- 
substance itself. The various symptoms which we observe 
consecutively in the living subject depend upon the seat 
and extent of the partial or total destruction of nervous 
tissue by the processes mentioned. 

Syphilitic Diseases of the Periphery of the 
Brain. — Chronic, exudative, fibrous, hyperplastic in- 
flammation of the meninges rarely occurs alone, being 
usually combined with gummata. The gummy deposi- 
tions are found chiefly in the neighborhood of the cerebral 
arteries and nerves; the cranial nerves at their exit are 
enclosed in the masses of exudate in the subarachnoid 
space. The diffuse, fibrous neoplasms spread out over 
larger or smaller areas and produce adhesions of the 
meninges to each other and to the surface of the brain, 
so that several dry, cheesy gummatous foci may become 
enclosed. Fibrous as well as gummatous neoplasms ex- 
tend to the cortex or even to the white matter. The 
cranial nerves which become involved in this process at 
the base of the brain are : the optic chiasm, oculomotor, 
trochlear, abducent, trigeminal, facial, glossopharyngeal, 
vagus, spinal accessory, and hypoglossal. 

Gummata arising in the brain-substance itself often 
attain to a considerable size and, according to their seat, 
produce phenomena similar to those produced by other 
neoplasms. Such a gummatous encephalitis may be 
widely distributed over the cortex, the white matter, 
and the base of the brain without involving the meninges. 

The diseases of the cerebral arteries are of "the 
greatest importance ; Ave have already made their ac- 
quaintance under the name of syphilitic endarteritis. 
They are more or less significant, according as the 
branches involved are end- vessels or not. The occlusion 
of the cerebral vessels which ensues is followed by nutri- 
tive disturbances in the brain-substance, softening, and 



62 SYPHILIS. 

destructive hemorrhages of greater or lesser intensity. 
Areas of softening or necrosis of the brain develop, such 
as we find, for instance, in the basal ganglia, the pons, and 
medulla oblongata, or there may be no more than a state 
of impaired nutrition, as there is a possibility of collateral 
circulation being established. 

As we have intimated above, these anatomical altera- 
tions alluded to give rise to a very great variety of symp- 
toms. The most important for the estimation of the 
gravity of the disease are headache, insomnia, vertigo, 
disturbance of consciousness and intelligence, etc. 

Depending upon the position of the morbid focus, be it 
a gumma or an encephalomalacia, there will be paralyses 
and disturbances of sensibility. 

The psychical disturbances which frequently accompany 
the conditions referred to have no definite anatomical 
foundation ; they are caused by the grave nutritive dis- 
turbances in the brain either from the general cachexia or 
from a local process. 

Diseases of the cortex may be produced by gum- 
matous infiltrations or by encephalomalacial processes 
following the occlusion of a main artery (for instance, 
the middle cerebral artery), in which case the motor 
centers (the facial nerve), the centers of speech and of 
sensibility, as well as the intellectual centers, may be 
seriously injured. The paralysis may attack several 
groups of muscles in succession, or involve the entire 
extremity from the start. Sometimes cortical epilepsy 
occurs, showing itself in tonic and clonic spasms of single 
muscle-groups, or in epileptic convulsions affecting the 
entire half of the body. The epilepsy is attended with 
loss of consciousness. Temporary aphasia is usually 
present in cortical syphilis. 

Cerebellum. — The diseases of the cerebrum which 
have been mentioned may under similar conditions affect 
the cerebellum also. In this situation they produce dis- 
turbances of the equilibrium, and are often combined 
with violent headache, vertigo, and pressure-sensations. 



TERTIARY SYPHILIS. 63 

Although syphilitic processes in the brain present sub- 
stantially the same symptoms as other cerebral diseases, 
there are certain combinations that are typical of specific 
disease and constitute a characteristic symptom-complex : 
this is the case in syphilis of the base of the brain. 
If the bones through which the cranial nerves pass are 
diseased, the nerves themselves become involved. The 
gummatous process attacks the perineurilemma and de- 
stroys the nerve-elements. Hence the chief consequence 
of disease of the base is the paralysis observed in these 
nerves, particularly the ocular nerves. 

Gummatous diseases of the meninges which affect the 
pons or the peduncle of the cerebellum and produce 
paralysis on the side of the body opposite to the seat of 
the lesion are also accompanied by paralyses of the same 
side ; this often happens in the case of the oculomotor, the 
abducent, and the facial. 

Syphilitic disease of the arteries at the base of the 
brain, which Ave mentioned above, and gummata in the 
same situation are followed by very complicated phe- 
nomena, being characterized by paralyses in the peripheral 
distribution of the cranial nerves. In all cases of exten- 
sive gummata or foci of softening various nerve-paralyses 
are always associated with peripheral paralyses. It there- 
fore becomes necessary to determine whether they are due 
to nerve-lesions within or without the brain-substance. 

Syphilitic disease of the spinal cord, whether 
primary or secondary to disease of the meninges, is 
characterized by the occurrence of limited gummatous 
areas or by fibroid change in the meninges. Thus the 
myelomalacia may attack only peripheral portions of the 
white matter, or it may involve the gray matter as well. 
The resulting clinical pictures of myelomeningitis and 
myelitis present many variations, depending upon the 
particular segment or number of segments involved ; w T e 
shall not enter into a detailed description of them at this 
point. 

It might be well to call attention to a certain clinical 



64 SYPHILIS. 

picture often seen in syphilis, a kind of tabes character- 
ized, usually, by the absence of the Argyll-Robertson 
pupil and optical atrophy. Such cases should be carefully 
watched for some time and the effect of antisyphilitic 
treatment observed, before the patient is promised a cure. 
As regards the classic form of tabes, we know only that it 
often develops in syphilitic patients ; we have as yet no 
knowledge of any intimate relation existing between the 
two processes. 

The nerve-roots and the cauda equina may be 
attacked by secondary (meningitis), or by primary (oculo- 
motor nerve) neuritis. 

In conclusion, a word in regard to various neuroses in 
the peripheral nerves which we have observed in the 
course of a syphilitic process. 

Such neuroses may occur in the distribution of the tri- 
geminal or of the facial, or in peripheral nerves like the 
ulnar and sciatic. They begin with sensory disturbances 
which soon become extremely painful ; later there may be 
motor and even trophic disturbances. The prognosis is 
good, however, and we have often been able to effect a com- 
plete cure by antisyphilitic treatment. But if the neuro- 
sis persists, atrophy and loss of function may result. 

HEREDITARY SYPHILIS. 

The term hereditary or congenital syphilis is applied to 
the disease when the fetal organism becomes infected in 
utero. The germ may become infected at the time of 
impregnation if the germ-cells of one or both parents are 
diseased (so-called germinal infection), or the offspring 
becomes infected during its development in utero before 
birth. While it is impossible to formulate definite laws 
of heredity, we submit the following generally accepted 
theories : 

1. If both parents are syphilitic before conception, the 
more recent their own infection the greater the danger of 
infection to the offspring. The power of transmission in 



HEREDITARY SYPHILIS. 65 

most cases decreases from about the fourth year after in- 
fection, but it may be present as late as fourteen or fifteen 
years after that event. Syphilitic parents may produce 
syphilitic children, not only during the periods when 
demonstrable symptoms are present, but also during the 
intermission periods. 

2. The most frequent infection is from the mother 
(ovular infection). Again, the duration of the mother's 
syphilis plays an important role. Recently infected 
mothers, with few exceptions, always infect their off- 
spring ; if, on the other hand, the infection is of longer 
standing, a relatively healthy child is occasionally born 
between two syphilitic children. 

3. If the mother is infected during pregnancy, the 
child may also become infected in utero through the 
placenta. It is generally held that the placenta must 
first become diseased before such postconceptional infection 
can take place. 

4. According to many observers, a syphilitic father is 
capable of infecting his offspring with syphilis at the time 
of impregnation (spermatic infection). If the mother has 
been infected at the same time by her syphilitic husband, 
she becomes immune through gestation of the syphilitic 
fetus; she can nurse her diseased child without incurring 
the danger of becoming infected by it (Colles's law). Ex- 
ception has been taken to this law because once a mother 
was infected by her syphilitic child, and in another in- 
stance a mother who had given birth to a syphilitic child 
was infected at the end of her pregnancy. 

The syphilis of the parents, especially of the mother, 
has such different effects on the syphilis of the offspring 
that little or nothing positive can be said concerning its 
influence. 

If both parents, and especially the mother, contract 
syphilis shortly before conception takes place, the fetus 
soon dies in utero and abortion occurs during the third or 
fourth month. Various factors are concerned in this 
result : the diseased embryo is incapable of development, 

5 



66 SYPHILIS. 

the mother's nutrition is so much impaired by her disease 
that she is unable to nourish the fetus properly, the uterus 
itself may be diseased, or the placenta is so altered by the 
syphilitic disease of the blood-vessels that the fetus cannot 
be nourished and therefore dies. 

While this is unfortunately the most frequent termina- 
tion of such pregnancies, there are other cases in which 
the fetus goes on developing until the seventh or eighth 
month and is then born prematurely, a sickly child, or is 
stillborn at the end of pregnancy. Finally, the child 
may be born alive, but with such grave syphilitic disease 
that it succumbs in a few hours or days. Such births 
occur chiefly when the parents have been suffering from 
syphilis for some time and in cases where the virulence 
of the disease has been reduced by palliative treatment. 

Parents in the gummatous stage of syphilis usually pro- 
duce healthy children. The author has known many 
cases of comparatively severe tertiary disease on the part 
of the mother during pregnancy, which nevertheless 
terminated favorably. It is a curious and hitherto unex- 
plained fact that a relatively healthy child, practically 
free from specific symptoms, may be born between two 
diseased children. 

It follows from what has been said that it is impossible, 
in a case of positive syphilis of the parents, to predict 
whether the offspring will be healthy or diseased ; experi- 
ence, however, teaches that careful treatment of the par- 
ents affords the best guarantee for the proper development 
of the offspring. 

The history of many countries which have been visited 
by epidemics of syphilis shows what a decimating effect 
hereditary syphilis has on the population. To-day the 
eloquence of figures confirms what had been obtained by 
induction : 

Von Wiederhofer estimates the mortality of syphilitic 
infants to be 99 per cent. Fournier has constructed the 
following table for the mortality of the offspring of syph- 
ilitic parents ; 



HEREDITARY SYPHILIS. 67 

When both parents are syphilitic, 68.5 per cent. 
When the mother is syphilitic, 60.0 per cent. 
When the father is syphilitic, 28.0 per cent. 

Hereditary syphilis is conveniently divided into an 
early (syphilis hereditaria praecox), and a late 
form (syphilis hereditaria tarda). 

A fetus that dies early rarely exhibits any pathological 
changes. In stillborn children certain pathological altera- 
tions are almost constantly found in many organs ; the 
most important of these are osteochondritis at the epiph- 
yses of the long bones, enlargement of liver and spleen, 
abscess in the thymus gland, and disease of the heart 
and blood-vessels and of the digestive tract. To these 
are added, in the order of decreasing frequency, diseases 
of the nervous tissues, of the kidneys, testicles, etc. It 
is not within our province to describe these important 
and interesting alterations in detail, and we shall merely 
mention a few phenomena of practical clinical importance 
observed in hereditary syphilis. 

One absolutely fatal form of the disease sometimes 
declares itself at birth ; the term syphilis haemor- 
rhagica neonatorum is applied to it. The principal 
alterations occur in the blood-vessels and give rise to 
hemorrhages into the parenchyma of organs, particularly 
into the cellular tissue in which the vessels lie embedded. 
Death occurs very early, in the first few hours or at most 
within two days, with the symptoms of cardiac weakness, 
cyanosis, sometimes with peripheral edema, anasarca, or 
even ascites. The many hemorrhages on the body resem- 
ble small petechias ; sometimes more extensive extravasa- 
tions are found. 

The principal symptoms observed in syphilitic infants 
are the nutritive disturbances to which they are subjected 
while still in xdero. The body-weight is usually below 
normal ; the skin is withered and hangs in folds. Of the 
diseases which present visible alterations the most fre- 
quent is the so-called syphilitic pemphigus, which 



68 SYPHILIS. 

either exists at birth or develops within the first three or 
four days. The vesicles of this exanthema are collapsed 
and either burst or dry up, leaving excoriations or sores 
covered with scabs on the thin, pale skin (PL 58). The 
internal organs of such children are always diseased, and 
they pine away in spite of the most careful nursing. 
They usually die of inanition in one or two weeks; it is 
rarely possible to keep them alive longer than that. 

In the very first days of the infant's life disease of 
the navel plays an important part ; in spite of the 
greatest care hemorrhages and ulcerative processes occur 
and are often followed by general septic infection. 

Septic infection and the entrance of various bacteria 
are favored not only by the umbilical lesion, but also by 
the many sores on the skin caused by the exanthemata. 
Furunculosis, long held to be a syphilitic product in the 
skin, is an example. All these adverse conditions com- 
bine to bring on the speedy death of the already debili- 
tated infant. 

Another very frequent disease is snuffles, which early 
declares itself in syphilitic infants. The mucous mem- 
brane of the nose becomes swollen ; dyspnea is the most 
distressing symptom, the excessive secretion being of sec- 
ondary importance. The infiltration spreads from the 
mucous membrane to the perichondrium and periosteum, 
and finally results in the formation of a saddle-nose (PI. 
60c). 

Before long, papular eruptions appear on the nates and 
about the genitals at the junction between mucous mem- 
brane and skin. The papules become macerated and 
form ulcers or fissures at the angles of the mouth and 
about the nostrils. In addition, vesicopustular exanthe- 
mata appear on the skin which soon desiccate and leave 
brown scabs. 

The matrix of the nails, the palms of the hands, and 
the soles of the feet are also attacked by eruptions. 

Diseases of the eyes, such as iritis, keratitis, etc., 
occur ; they give rise to pronounced swelling of the con- 



HEREDITARY SYPHILIS. 69 

junctiva, purulent secretion from the conjunctival sac, and 
to erosions and fissures at the corners of the eyes. 

These symptoms are associated with enlargement of the 
liver and spleen, affections of the bowels, pulmonary 
catarrh, which are caused by aspiration of the secretions 
from diseased buccal and nasal cavities, and not infre- 
quently cause death within two or three months. 

If the infant lives through all these graver troubles, 
other phenomena soon make their appearance. The dis- 
eased epiphyses, which hitherto had escaped notice, 
become detached, beginning usually at the humeral joint. 
At first a painful swelling appears about the affected 
epiphysis and the limb hangs down as if it were paral- 
yzed. Sometimes it is possible to determine the condition 
by the abnormal movability, but usually the picture is 
simply that of palsy. 

Even after all the symptoms in the skin, mucous mem- 
branes, and joints have disappeared, the children are still 
weak and anemic, and we can readily understand that 
they suffer more severely than other children from inter- 
current diseases, such as bronchitis, pneumonia, intestinal 
catarrh, etc. 

This early period of hereditary syphilis is sometimes 
followed by late forms, like the tertiary forms of ac- 
quired syphilis, for which the term syphilis hereditaria 
tarda is used. 

It is asserted by some observers that this late form of 
syphilis may occur between the ages of sixteen and 
twenty or over, without having been preceded by any 
other form of the disease. But it is to be remembered 
that hereditary syphilis does not necessarily produce very 
marked changes in the child, and Ave cannot therefore 
agree with this view. Good health is a relative term and 
very elastic in its application. A slight nose-trouble and 
tardy development are phenomena which may easily 
escape detection. In treating advanced forms of syphilis 
I have found the marks of severe processes in the skin, 
glands, and joints which had not been attributed to syph- 



70 SYPHTLIS. 

ilis. There is still a general impression that syphilis 
always gives rise to definite symptoms, especially such 
as can only be cured by specific treatment. These and 
many other reasons account for the different and erroneous 
views which are held about the late form of hereditary 
syphilis. 

It is important to distinguish between infantile ac- 
quired syphilis and the hereditary form. I have often 
had occasion to treat patients between 16 and 18 years 
of age for the later forms of syphilis. In such cases the 
most careful inquiries must be made whether the parents 
ever suffered from diseases which might have had a spe- 
cific origin, what the history of the confinements in the 
family has been, whether any children were stillborn, and 
whether there are any brothers or sisters affected with 
syphilis. If any such signs of hereditary syphilis were 
found, the patients never failed to show disturbances of 
development or other signs of hereditary disease. If no 
such indications were found, the case usually turned out 
to be a tertiary form, the infection having been acquired 
early, without the knowledge of the patient or of his 
family. 

The late forms of hereditary syphilis begin to show 
themselves about the fifth year, sometimes with the ap- 
pearance of puberty about the twelfth year; we have 
observed them to last, with interruptions, as late as the 
twentieth year. 

It is not our purpose in this place to discuss in detail 
all the protean forms to which hereditary syphilis gives 
rise sooner or later in the organism ; we shall content 
ourselves with mentioning the most striking symptoms 
which help the physician to determine whether a given 
morbid product is to be attributed to syphilis or not. 

To Hutchinson is due the credit of collecting a group 
of symptoms which enable us to distinguish tertiary 
hereditary forms from acquired syphilis with great accu- 
racy. They are : A deformity of the permanent upper 
incisors, consisting in a crescentic notch on the free edge 



HEREDITARY SYPHILIS. 1\ 

of the teeth. A dimness of the cornea, or an existing 
interstitial keratitis (Plates 60a, 60b ; black plate), and 
rapidly increasing deafness. If we add a prominence of 
the frontal protuberances, flat or even depressed nose, and 
fine scars at the angles of the mouth, the upper lip, and 
the mucous membrane of the lips, radiating from the 
nares, the picture is complete. Fournier is quite right 
when he points out the tardy development of such indi- 
viduals. They look like children even at the age of 16 
or 18 ; the genitals, the pubic hairs, the breasts in the 
female subjects, are imperfectly developed. 

As to the symptoms of tardy syphilis, they include 
the lesions in the bones and joints which we find in the 
acquired form, and skin-lesions in the form of gum- 
matous, serpiginous ulcers. The skin of the nose seems 
to be a favorite seat. This is perhaps due to the chronic 
catarrh which is so often present ; ulcers gradually form, 
the process spreads to the cartilages and to the bones, and 
at last the external skin is also destroyed. 

Certain groups of lymph-glands, notably the cervical 
glands, undergo a peculiar form of hyperplasia resulting 
in large tumors, which show no tendency to soften or 
break down. The condition usually lasts a long time 
and resists treatment much more stubbornly than do the 
other symptoms. Such glandular tumors resemble sar- 
coma. 1 

The internal organs, liver, spleen, and kidneys, are 
usually enlarged, and often irregularly contracted by 
gummata and cord-like neoplasms. The most frequent 
alteration in these organs is amyloid degeneration, espe- 
cially if the patient is debilitated. 

The nervous system does not escape the ravages of the 
morbid process. The patients frequently suffer with 
epileptiform attacks ; they possess a low order of intel- 
ligence and are sometimes even half-witted. The same 
diseases of the meninges, the arteries, and of the brain- 
substance occur as are found in acquired syphilis, and the 

1 As in one of my cases in the Kudolfsspital ; see Yearly Report, 1892. 



72 SYPHILIS, 

diagnosis must be based on the evidences of the presence 
of syphilitic processes in other parts of the body and on 
the loss of the cerebral functions. 

It is difficult even to outline the proper treatment 
for hereditary syphilis. In every case the patient 
requires the most careful management, if there is to be 
even a chance of success. Drugs should be administered 
from time to time, particularly iodids and tonics ; in the 
early forms modified inunction cures and sublimated 
baths may be employed. The greatest benefit is derived 
from careful dieting, good, pure air, and baths containing 
iodids — more than from a general treatment. 

THE TREATMENT OF SYPHILIS. 

We shall divide the treatment of syphilis into three 
subdivisions: 1. Initial forms and their immediate con- 
sequences ; 2. Local treatment of the secondary and ter- 
tiary lesions; 3. General treatment of syphilis. 

i. Initial Forms and Their Immediate Consequences. 

It is the duty of the physician to treat every sus- 
picious lesion as if syphilitic infection had actually 
occurred. The ruling principle must be to destroy the 
syphilitic germ at the point of infection as soon as possible. 
As we have seen by the pathology, the first diagnosis can 
only be a provisional one, even if the case is seen in the 
first few days, but the physician is nevertheless justified 
in adopting energetic measures at once. It is impossible 
to say how long the virus remains at the point of entry ; 
certainly a very short time, for I have never had any 
good results from excision of a simple initial sore within 
thirty-six or even twenty-four hours. Although these 
excisions were made before any evidences of reaction to 
the poison had made their appearance, the virus was not 
removed, showing that it had already been communicated 
to the vessels and other parts of the body outside of the 



TEE TREATMENT OF SYPHILIS. 73 

initial sore. Nevertheless, excision is advisable in certain 
seats of syphilitic infection which are favorably situated 
for operation, as fissures in the preputial margin, in the 
edges of the labia, etc. The excision, to be justifiable, 
must be made within the first few hours after infection ; I 
have never known it to be successful in cases where a 
beginning infiltration or even a complete sclerosis could 
be demonstrated, although the treatment of the initial 
lesion was somewhat simplified by the operation. What 
has been said about excision is equally true of the use of 
the thermocautery ; the burn must, however, be treated 
longer than the wound from an excision, which may be 
allowed to heal by first intention. Cauterization is indi- 
cated only when the sclerosis has become phagedenic and 
is rapidly degenerating. 

In the initial forms we confine ourselves as a rule to 
the antiseptic treatment, using the customary drugs, corro- 
sive sublimate, carbolic acid, salicylic acid, etc. For 
many reasons, learnt in the prophylactic treatment of 
syphilis, it is not advisable to begin a general treatment 
at once, except in cases where the sclerosis is seated on 
the face — at the lips, for instance — and tends to degen- 
erate rapidly, with the formation of large glandular 
tumors. In such cases the practice has always been to 
endeavor to stay the destructive process by immediate 
resort to general treatment. 

In the male genitals the sclerosis is usually seated 
on the prepuce itself or in the neck of the penis, and is 
often associated with phimosis. If the foreskin was too 
long originally (prseputium perlongum), and is converted 
into a hard mass by the infiltration spreading beyond the 
initial sclerosis, it must be removed with the knife in 
order to shorten the treatment and put an end to the 
patient's distress. It is not necessary, or even advisable, 
to remove the entire prepuce ; it is enough to open the 
preputial sac at the dorsum and excise a portion of it. 

If the sclerosis becomes gangrenous and destroys the 
inner layer of the foreskin or the neck of the penis, im- 



74 SYPÜTLM 

mediate operation becomes necessary. After the opera- 
tion such phimoses heal readily and give no further 
trouble ; even the remains of the edges of the sclerosis 
heal and leave a scar. 

If there is a paraphimosis from forced retraction of the 
infiltrated prepuce, surgical interference becomes neces- 
sary to prevent further destruction of the prepuce and of 
the skin of the penis by the pressure of the constricting 
preputial ring. 

The dorsal lymphatics, owing to the infiltration in sim- 
ple, non-ulcerative scleroses, are converted into hard, 
sometimes nodular welts ; these may be covered with 
strips of gray plaster ; they soon disappear when the 
general treatment is begun later on. 

The glandular swellings of syphilis rarely go on to 
suppuration unless they are complicated with venereal 
ulcers, or the patients are scrofulous or otherwise debili- 
tated. In such cases the adenitis is to be treated sur- 
gically in the manner indicated in the section on vene- 
real ulcers. 

In treating scleroses in the female genitals the only 
difficulties are encountered in applying the remedy and 
getting the bandage to stay. Powders and strips of gray 
plaster are employed with advantage ; a T-shaped band- 
age will keep the dressing on the external genitals in 
place. 

Scleroses at the orifice of the urethra and about the anus 
may be treated at first with bougies and suppositories of 
iodoform (iodoformi puri, 0.1 (gr. xv) ; olei theobroma?, 
q. s. u. f. suppositor. urethrale), and later with strips of 
gray plaster. Sometimes a dressing of antiseptic gauze, 
saturated with a 5 per cent, solution of white precipitate 
or a 1 to 3 per cent, solution of red precipitate may be 
employed with advantage. The dressing must be changed 
from one to three times a day, according to the amount of 
secretion, and the ulcer cleansed each time with carbolic 
acid or corrosive sublimate. 



THE TREATMENT OF SYPHILIS. 75 

2. Local Treatment of the Secondary and Tertiary 

Lesions, 

In syphilitic affections of the mouth, nose, and 
throat the patient must use a mouth-wash and gargle 
several times a day, especially after meals and before 
retiring at night. 

The following prescriptions are recommended : 

fy. Pot. chlor., 10.0 (sijss) ; 

Aq. desk, 500.0 (Oj). 

S. : Gargarisma. 

^. Pot. chlor., 10.0 (sijss) ; 
Alum, crud., 1.0 (gr. xv) ; 

Aq. dest., 400.0 (fsxiij) ; 

Aq. menth. pip., 100.0 (fgiij). 

S. : Gargarisma. 

ty. Acid, borac, 10.0 (sijss) ; 

Solve in aq. dest., 500.0 (Oj). 

S. : For external use. 

^. Acid, salicyl., 3.0 (gr. xlv) ; 

Spirit, vin. rectif., 30.0 (f Ij) ; 

Aq. dest., 300.0 (f In) ; 

Tinct. kramerise, gtt. xxx ; 

Pot. hypermang., 5.0 (,"jss) ; 

Aq. dest, 100.0 (fgiij). 
S. : One tablespoonful to a glass of water for mouth- 
wash and gargle. 

Jy. Tinct. cascarillse, 
Tinct. cinchona?, 
Tinct. kramerise, 

Spirit, menth. pip., ää. 25.0 (3vj). 
S. : Twenty drops to a glass of water for mouth -wash. 

Ulcerative, papular sores on the mucous mem- 
brane of the lips and cheeks and on the isthmus 



76 SYPHILIS. 

of the fauces must be touched with nitrate of silver 
every clay by the physician himself (solid nitrate or a 
5 per cent, solution). If the patient is a responsible 
person, he may be trusted with a sublimate mouth-wash, 
either in the form of tablets prepared with NaCI, 1 gram 
(gr. xv) each, to be dissolved in water, and used in the 
proportion of one tablespoonful of the solution to ten 
tablespoonfuls of water as a gargle ; or 

Ify. Hydr. bichlor. corros., 1.0 (gr. xv) ; 
Alcohol, absol., 50.0 (f^jss). 

S. : Poison. — One tablespoonful to a glass of water 
for mouth- wash. 

These sublimate gargles are to be used two or three 
times a day, an entire glassful being used each time. 

Ulcers and fissures on the tongue must also be 
touched with nitrate of silver. Hard infiltrates on the 
surface of the tongue should be painted with a more con- 
centrated alcoholic solution of sublimate, or with tincture 
of iodin, once or twice a day. 

Destructive gummata and ulcers on the mucous 
membranes must be energetically treated with solid nitrate 
of silver and thoroughly cleansed with one of the above- 
mentioned mouth-washes or with an irrigator. In using an 
irrigator for the nasal cavity, care must be had not to exert 
too much pressure, lest the liquid be forced into the cranial 
cavity or into the Eustachian tube and cause pain. If 
there are any necrotic bone-fragments at the bottom of 
the ulcers or between the proliferations of granulation- 
tissue, they must be removed as soon after they have 
separated as possible. If the operation is attended with 
hemorrhage, which is often the case, absorbent cotton or 
adhesive iodoform gauze may be used to control it. 

The local treatment of laryngeal Syphilis requires 
some proficiency in the use of the laryngeal mirror and 
other instruments, and should only be attempted by a 
specialist. Inhalation of the vapors of iodid solutions 
(2 per cent, potassium iodid), as an adjunct to the general 



THE TREATMENT OF SYPHILIS. 77 

treatment, is allowable in very light cases ; it is, however, 
usually inadequate for the removal of the larger forms 
of papules, or of extensive infiltrations, or even of deep 
gummy ulcers. 

For papular syphilides on the genitalia and 
anus, the most frequent form of syphilis in the female, 
and very apt to recur in both sexes, we use Labarraque's 
dressing : 

^. Chlorin. liquid., 20.0 (f3v) ; 

Aq. dest., 80.0 (fgijss). 

S. : Apply with a brush. 
And 

]^. Calomel, 
A myl, ää. 
S. : Dusting-powder. 

The papules are first moistened with the chlorin- 
water and then dusted with calomel. Sublimate in the 
nascent state is thus formed, which acts as an intense 
caustic without giving much pain. 

In the severe hyperplastic forms affecting the labia 
majora, the perineum, and the nates, the infiltration may 
be made to subside rapidly by painting daily with a 
stronger alcoholic or ethereal solution of sublimate (1 : 20) 
and covering the moistened parts with strips of cotton. 
The use of caustics, such as sublimate collodium (1 : 20), 
Plenck's solution l , and others, has been given up as too 
dangerous as well as painful. Even the solution we have 
indicated must be applied with great care, so as not to 
touch any but the hyperplastic tissues ; if the burning is 
severe, it should be followed by the application of alum- 
inum acetate or Burow's solution in the form of com- 



Hydr. chlor, corros., 




Aluminis, 


ää. gj ; 


Plumb, ace tat., 




Camphor., 


ää. gj; 


Alcohol., 




Acid, acet., 


ää. ^xij 



78 SYPHILIS. 

presses. Inunctions with stronger white precipitate some- 
times have a good effect. 

Jfy. Hydrarg. ammoniat., 5.0 (3Jss) ; 
Unguent, emollient., 40.0 (gx) ; 

either alone or reinforced by 0.1 (gr. jss) sublimate. 

For flat papules which do not secrete much a good 
adhesive gray plaster answers every purpose. 

Fissures about the anus, which are usually found 
close to proliferated anal folds, often defy all remedies and 
are best treated surgically. The proliferations are re- 
moved with Paquelin's thermocautery, the patient being 
anesthetized, and the wound is afterward dressed with 
iodoform vaselin or with white-precipitate ointment. 
Tying the infiltrated folds with elastic ligatures is not 
to be recommended, although I formerly employed that 
method in a good many cases without injury to the 
patients. 

Palmar and plantar psoriasis, fissures and 
degenerating papules between the toes and on 
the fingers. In all these forms the hands and feet should 
be softened by soaking in warm water (with soap) and 
then dressed with good, soft gray plaster. Deep fissures 
or ulcers with signs of inflammation are to be treated 
with baths and compresses dipped in Burow's solution. 
Sometimes it is advisable to apply sublimate solutions 
(1 : 1000) in addition to the bathing. A very good plan 
is to rub the affected parts with the above-mentioned 
white-precipitate ointment (4 : 40, with 0.1 to 0.2 (gr. jss 
to iij) sublimate) after bathing them at night, and then 
to put on a pair of Swedish leather gloves. 

Syphilitic onychia and paronychia are treated 
with warm-water baths, compresses, and washing with 
sublimate, the diseased end-phalanges being well tied up 
in caps of gray plaster. If the edges of the nails are 
turned in, a local anesthetic is administered, the nail is 
split, and the edges are cut away. A protecting bandage 



THE TREATMENT OF SYPHILIS. 79 

or finger-cot should be worn constantly until the nail 
grows again. 

In diseases of the scalp, which we have described, some 
form of local treatment is always necessary. First of all, 
the hair is to be cut short. The patient must wash his 
head every day with soap and water and rub it with 
white-precipitate ointment (1 : 10). If pustular ulcers or 
deep, destructive gummata are present, the scalp must be 
dressed with iodoform vaselin, mercurial ointments, or 
with gray plaster, and the dressing held in place by a 
properly applied head-bandage. Carious bone-lamella? 
either separate of their own accord or, if necessary, are 
removed with forceps. The local treatment must never 
be omitted, as it may be the means of avoiding an 
extensive necrosis of the bone even when large areas are 
exposed. I have seen holes in the skull as large as a dol- 
lar heal over and form a scar. If the loss of bone-sub- 
stance is considerable, insert plates of celluloid after the 
scar has formed, in order to protect the brain. 

The treatment for the various cutaneous processes, 
the muscle-, bone-, and joint-lesions of the later 
stages of syphilis, cannot well be reduced to a schedule. 
If the numerous external remedies are insufficient to con- 
trol the process, and surgical interference is indicated, it 
should not be delayed too long. We are getting over our 
reluctance to operate on syphilitic patients. 

3. General Treatment of Syphilis. 

To begin with, the so-called expectant treatment, by which 
is meant the regulation of the diet and other hygienic con- 
ditions, without the use of the specifics mercury and iodin 
for the local lesions, is in our opinion entirely inadequate. 

As soon as syphilis produces lasting functional disturb- 
ances in the circulatory organs, neuralgias or pathological 
changes in the skin or mucous membranes remote from the 
point of infection, the physician must begin a specific mercu- 
rial treatment and persist in it until the morbid symptoms 



80 SYPHILIS. 

have disappeared completely. In fact, experienced prac- 
titioners make it a rule to continue the treatment for a 
period equal to at least a third or even a half of the dura- 
tion of the symptoms, after the latter have disappeared. 

Any subsequent relapse, if accompanied by marked 
alterations in various parts of the body, must again be 
subjected to both general and local treatment. Thus we 
follow the pathological process and keep the patient 
under observation, treating him with mercury, or later 
with iodid, only when he actually shows unmistakable 
syphilitic symptoms. We do not advocate the practice 
of giving drugs at definite intervals, whether the symp- 
toms are present or not (chronic intermittent treatment 
— Fournier), because we have noticed that such a course 
does not prevent the recurrence of the symptoms after a 
certain period ; besides, the patient becomes accustomed 
to the drug and does not respond so readily when it be- 
comes necessary to give it to him at the next outbreak of 
the disease. But this is not the place to discuss this ques- 
tion in detail ; we only wished to define our position. 

For headache, insomnia, and other distressing symptoms 
which sometimes occur during the eruptive period, we 
prescribe : 

Ify. Pot. brom., 

Sod. brom., ää. 4.0 (sj) ; 

Ammon. brom., 2.0 (3ss). — M. 

Ft. pulv. No. x. 
S. : 1 or 2 powders at bedtime. 
Or 

1^. Pot. brom., 

Pot. iod., ää. 0.5 (sjss). — M. 

Ft. pulv. No. x. 
S. : 1 or 2 powders at bedtime. 

Before the appearance of the exanthemata and in the 
intervals between the relapses (if there are any) and the 
consequent specific treatment, we have various duties 



THE TREATMENT OF SYPHILIS. 81 

toward the patient to fulfil. We must prepare him for 
the various forms of mercurial treatment — the mouth and 
the skin must be looked after, the initial lesion treated 
locally ; and after the course of specific treatment is over 
he requires a supplementary one, such as medicinal baths, 
tonics, etc. 

The Cake of the Mouth before and during 
Mercurial Treatment. 

We cannot emphasize too strongly that a systematic, 
careful treatment and supervision of the mouth is an abso- 
lute necessity during the entire course of mercurial treat- 
ment, and even longer. The patient must clean his teeth 
three or four times a day with brush and powder. In our 
hospital practice we use the following : 

^. Pulv. dentifr. nigr., 50.00 (Ijss). 
Or 

Ify. Calcar. carbon, pulv., 50.00 (Ijss) ; 

Magnes. carb., 10.00 (sijss) ; 
Pulv. rad. ir. nor. (orris), 20.00 fev) ; 
Olei menth. pip., (gtt, lx). — M. 

S. : Tooth-powder. 

After that the gums are painted with an astringent 
tincture, and then rinsed with water. 

Tfy. Tinct. iodin., 

Tinct. gall., ää. 10.00 (3ijss). 

S. : Apply with brush. 



Or 



Or 



3^. Tinct. kramerise, 

Tinct, gall., ää. 20.00 (sv) ; 

Olei menth. pip., (gtt. xl). 

S. : Gum tincture. 

1^. Ol. cadin., 

Spir. vin., ää. 10.00 (gijss) ; 

Tinct, laud, simpl., 5.00 (3Jss). 



Or 



82 SYPHILIS. 

As a gargle we prescribe hypermanganate of potassium 
in the usual pink solution, 0.5 to 2 per cent, potassium 
chlorid, in solutions of 1 to 2 per cent, with the addition 
of alum, or 

I$*. Aq. calcis, 

Aq. destill., ää. 

1^. Acidi salicyl., 5.00 (sjss) ; 

Spir. frument., 

Aq. destill., ää. 100.00 (f giij) ; 

Ol. menth., (gtt, v).— M. 

S. : One teaspoonful to a glass of water. 

In mercurial Stomatitis, in addition to the above- 
mentioned local measures, we paint the gums with nitrate 
of silver (1 : 30 to 1 : 15), rinsing the mouth with a saline 
solution, or with a 15 to 25 per cent, watery solution of 
chromic acid. Erosions and ulcers are touched with the 
solid stick of silver nitrate, or the recently suggested 
combination of silver nitrate with a 25 per cent, solution 
of chromic acid may be employed. By this method the 
newly formed argentic Chromate leaves a red scab on the 
surface of the ulcer. 

Mercurial Treatment of Syphilis. 

The sovereign method of applying a mercurial cure is 
inunction with gray mercurial ointment; it is 

applicable not only to all forms of syphilis, but to all 
ages as well. 

The infant can be rubbed by the mother or nurse after the 
morning bath with dilute mercurial ointment (1.0 (gr. xv) 
unguent, einer, with 1.0 (gr. xv) ung. simpl.) on the sides of 
the thorax and on the abdomen. An adult weighing about 
60 kg. should use from 4 to 5 g. (3j to gjss) daily. The 
inunction ought to be performed by an expert masseur, 
but if that is impossible, as in hospital practice, the 



THE TREATMENT OF SYPHILIS. 83 

patient must be taught to do it himself. A small amount 
of the ointment is taken at a time and rubbed in alter- 
nately on both sides of the body till the skin is quite dry. 
The places selected for the inunction are usually the 
calves of the leg, the inner surfaces of the thighs, the epi- 
gastric region, the lateral regions of the thorax, the inner 
surface of the upper arm and forearm, and the back. 
After all these parts have been well rubbed, the patient 
should take a warm bath for the sake of cleanliness. 

The inunctions are to be kept up until all the symp- 
toms have disappeared, and after that for an additional 
period equal to one-third or one-half of the time occupied 
by the original treatment. If the patient is unwell from 
any accidental cause, or if he suddenly develops pro- 
nounced mercurial salivation and stomatitis, the treat- 
ment must be discontinued for a few days until the 
troublesome symptoms have subsided, and then resumed. 
There is no objection to repeating the treatment for every 
one of the many relapses which usually mark the course 
of a syphilitic disease. 

In addition to the inunctions, other measures, such as 
the baths we have referred to, and internal remedies, 
tonics, etc., may be employed. 

The patient must be well fed and housed while he is 
undergoing the treatment. If his work exposes him to 
hardship and fatigue, especially to the inclemencies of the 
weather, the treatment should not be used. We have 
never seen any good result from it under such circum- 
stances ; the patient becomes anemic and the treatment 
seems to do him more harm than good, so that he only 
loses faith in it. 

The physician must give his attention to the care of 
the mouth, as in all forms of mercurial treatment, and 
also to the digestive organs and to the excretions. We 
have on several occasions found albumin in the urine, 
and have been obliged to reduce the dose or to interrupt 
the treatment ; in a few cases we have even been com- 
pelled to give it up altogether. 



84 SYPHILIS. 

After the specific treatment is completed, the patient's 
mode of life must be properly regulated ; a mild water- 
cure, invigorating baths (salt-water baths), or, if possible, 
removal to a milder climate, should be recommended to 
supplement the specific cure. The mouth needs careful 
attention for weeks after the specific treatment is com- 
pleted. 

For the inunctions we prescribe in the case of adults : 

ly. Ung., einer., 4.0-5.0 (33 to 3Jss) ; 

Dent. tal. dos. ad chart, cerat. No. v. 
(Dispense five such doses in waxed papers.) 
S. : To be rubbed in (as indicated above). 

According to the Austrian Pharmacopea, 7th edition, the 
ointment is prepared as follows : 

^. Hydrarg., 

Lanolin, ää. 200.0 (,?ij), 

to be rubbed in until it disappears and then followed by 
the application of: 

^. Ung. simpl., 200.0 (gij). 

For extensive cutaneous syphilids, multiple 
ulcerative processes on the surface of the body, 
cutaneous exanthemata of the skin, and for 
weeping papules in small children, sublimate baths 
should be employed. 10-15 g. (gijss-sjv) in tablets. 
For adults 10-15 g. (^ijss-sjv) of sublimate solution are 
added to a bath of from three to five buckets of water at 
26° to 28° R. (32.5° to 35° C.) ; the patient remains in 
the tub from ten to fifteen minutes, during which time he 
is gently rubbed. After the bath he must stay in bed. 
Young children are simply sponged with the solution once 
or twice a day ; the diseased portions of the skin are first 
carefully washed and then dusted with a suitable pow T der 
(pure starch or starch mixed with calomel). 



THE TREATMENT OF SYPHILIS. 85 

Hypodermatic Methods. — (a) Soluble Mercurial 
Preparations : 

1^. Hydrarg. bichlor. corros., 0.10 (gr. jss) ; 
Sodii chlorati depurati, 1.00 (gr. xv) ; 

Aq. destill., 10.00 (feyss). 

Inject one syringeful of this solution daily, either sub- 
cutaneously in the back, or between the muscles (intra- 
muscular injection) in the nates. 

The following solution has been employed with great 
success, especially in the treatment of " walking cases " : 

fy. Hydrarg. bichlor. corros., 0.5 (gr. viij) ; 
Sodii chlorati, 2.00 (gss) ; 

Aq. destill., 10.00 (feijss). 

Inject one syringeful of this solution at intervals of 
five days or a week. If the precaution is taken to disin- 
fect thoroughly both the syringe and the place where the 
point is to be inserted, and the injection is followed by 
gentle massage of the part, there is practically no danger 
that the wound will be painful or that an abscess will 
form. 

(6) Insoluble Mercurial Preparations. — The use of these 
preparations is to be avoided, as a rule, for they all have 
the disadvantage that the amount of mercury absorbed 
necessarily remains an unknown quantity, as absorption 
varies greatly according to circumstances which cannot be 
controlled. Grave accidents sometimes occur in conse- 
quence of the sudden absorption of large quantities of 
the material supplied. 

However, we give some of the more common formula? : 

1^. Hydrarg. salicyl., 1.00 (gr. xv) ; 

Olei oliv, optim., 10.00 (sijss). — M. 

S. : To be injected. 

Shake before using. 



86 SYPHILIS. 

1^. Hydrarg. oxid. flav., 1.00 (gr. xv) ; 

Olei oliv, optim., 10.00 (3ijss). — M. 
S. : To be injected. 

Shake before using. 

1^. Calomelan., 1.00 (gr. xv) ; 

Olei oliv, optim., 10.00 (gijss). — M. 
S. : To be injected. 

Shake before using. 

Internal Use of Mercury. — This, as is well known, 
is the prevalent mode of treating syphilis in many coun- 
tries. In this country (Austria) it is used only for mild 
cases of relapse, and we do not recommend it under any 
other circumstances. 

Ify. Hydrarg. tannic, oxidul. (oxidu- 

lated mercuric tannate), 1.50 (gr. xxiv) ; 
Extr. laudan., 0.10 (gr. jss). — M. 

Div. in dos. No. xv. D. ad capsul. nebulos. 
S. : One pill after meals t. d. 

!ry. Hydrarg. bichlor. corros., 0.30 (gr. v) ; 

Extr. et pulv. rad. acori, act. 

q. s. f. pil. pond., 0.20 (gr. iij). 

No. xxx ; consperge pulv. liquirit. 
S. : One pill every evening. Increase the dose by one 
pill every day up to 3 or 4 pills a day. 

fy. Hydrarg. iodid. flav., 1.50 (gr. xxiv) ; 

Extr. laudan., 0.50 (gr. viij) ; 

Pulv. et extr. gent., q. s. ft. pilul. 

pond., 0.20 (gr. iij). 

No. 1. 
S. : 1 or 2 pills twice a day. 

Use of the Iodids in Syphilis. 

While the value of the various mercurial preparations 
in the treatment of syphilis is well established, and they 



TBE TREATMENT OF SYPHILIS. 87 

are found to be well nigh indispensable in four-fifths of 
the cases, the iodids form a most useful addition to the list 
of specific remedies. The iodids are indicated in general 
glandular enlargements, in the scrofulous diathesis, in 
accidental nervous complications such as headache and 
insomnia, and in cases where a long-continued course of 
mercury has proved useless. We must not be deterred by 
the incidental effects of iodid, such as catarrh of the nose, 
of the conjunctivae, and of the respiratory tract, frontal 
headache, and often gastric disturbances. After the treat- 
ment has been omitted for a few days and the symptoms 
have subsided, it may be resumed with smaller doses, until 
the organism gradually becomes accustomed to the drug. 
In the case of some patients, who at first complained of 
innumerable symptoms and protested vigorously against 
the drug, I have been able eventually to give the maximum 
dose, 5 to 10 to 15 g. (giss to 3iv), either by gradually in- 
creasing the dose or by varying the form. 

1^. Pot. iodid., 1.5 (gr. xxiv); 

Aq. destill., 100.0 (f giij). 

S. : Divide into 2 or 3 portions and drink during the 
day, diluting in fresh water. 

A better way is to give the patient some potassium iodid 
in a well-corked vial and let him prepare the solution 
himself. He can carry it about with him more easily, 
and the iodid, which is very sensitive to moisture, is pro- 
tected from the air and from dampness. If he is to in- 
crease the dose, he has his remedy always ready at hand. 
Some patients prefer to add a little fruit juice to the solu- 
tion in order to disguise the taste, others prepare a con- 
centrated watery solution and take it with milk. 

Sodium iodid contains less iodin than the potassium 
salt ; it may be given in the same form ; some patients 
take it more easily than the other preparation. 

Iodoform is not so suitable for internal use on account 
of its disagreeable taste ; it can only be taken in the form 
of pills. 



88 SYPHILIS. 

Iy. Iodof. pur., 10.0 (sijss) ; 

Extr. et pulv. acor. 
ää. q. s. f. pil. pond. 0.2 (-5ss). 

No. c, obteg. lamin. argent, (wrap in silver 
foil). 
S. : 2 or 3 pills morning and evening, before eating. 

We have lately tried iodothyrin (Baumann), not with- 
out success (in capsules containing 1 .0 (gr. xv), prepared 
with sacchar. lact). 

Tincture of iodin, which has occasionally been given 
in drops in a mucilaginous decoction, is not advisable on 
account of the gastric disturbances which it is apt to pro- 
duce. 

Last in the list of iodin preparations is ferric iodid : 

Jfy. Syrup, ferri iodid, 10.0 (sijss) ; 

Syrup, cort. aurant., 
Syrup, simp]., ää, 20.0 (3v) ; 

S. : 2 or 3 teaspoonfuls a day for adults ; 1 teaspoonful 
for children. 

It is a good remedy, either by itself or in conjunction 
with mercurial preparations. 

Medicinal Woods. 

Decoctions of sarsaparilla, lignum guaiac, etc., are 
to be regarded as simple cathartics, diuretics and sudo- 
rifics. Those which contain mercury or iodin, like 
Decoctum Zittmanni, are not without medicinal qualities. 
The latter remedy still enjoys a certain reputation. Pre- 
scribe 200 to 300 (f Hvj to f £ix) Zittmanni Decoctum for- 
tius, to be taken warm early in the morning. Decoctum 
Zittmanni mitius at night before retiring, usually taken 
cold. 

If these remedies are used, the diet must be strictly 
regulated. Cheese, salad, fresh fruit, beer, and all inflat- 



VENEREAL ULCERS. 89 

ing foods are to be avoided. The diet should consist 
principally of roasted meats, vegetables, tea, ham, soft- 
boiled eggs, and wheat bread. If the patient has more 
than four stools a day, the drug is too potent and the 
dose must be reduced. In many cases Decoctum Zitt- 
manni is used with advantage as an adjunct to the in- 
unction cure. 

In concluding this chapter on the general treatment, let 
me emphasize once more that the patient must keep his 
room well aired and well heated, and in the mild season 
must spend a good deal of time in the open air. He 
must have plenty of good, nutritious food. My own 
experience leads me to condemn all starvation or dry- 
bread " cures," combined with sudorific baths and other 
remedies calculated to weaken the organism. Although 
an apparent cure may sometimes be effected, and the 
symptoms temporarily subside, the treatment is of no 
lasting value; I have often had occasion to observe grave 
relapses within a very short time after such " cures." 

As supplementary cures we may recommend baths 
— sea-baths, hot baths containing iodin or sulphur, or a sys- 
tematic hydrotherapy, which is so effective in regulating 
various morbid conditions and tends to strengthen and 
harden the patient. 

VENEREAL ULCERS. 

It is now generally conceded that there is a form of 
ulcer quite distinct from the initial syphilitic lesion due to 
infection during sexual intercourse. It is the simple, 
venereal, contagious, non-indurative, soft ulcer, the so- 
called soft chancre. 

As we have already stated, this form of ulcer may be 
transmitted at the same time with syphilis, but it also 
occurs independently and has its own peculiar characters, 
both as regards its form and the consequences to which it- 
gives rise. 

The seats of the venereal ulcers are the external skin 



90 THE VENEREAL DISEASES. 

and the mucous membranes of the genital region and, 
under certain conditions, of the rest of the body. The 
specific bacillus, which has been isolated during the last 
few years (Ducrey-Krefting, Unna-Krefting), is contained 
in the pus and in the tissues of the ulcer. It gives rise 
to other similar ulcers which appear in series in the same 
organism and constitute a purely local disease. 

The ulcer develops almost immediately after infection 
has taken place through an abrasion of the skin or mucous 
membrane ; usually within twelve to twenty hours, in ex- 
ceptional cases after thirty-six to seventy-two hours. The 
purulent softening is at first circumscribed, but soon shows 
a tendency to spread, both downward and laterally, by 
suppurative destruction of the skin. When mixed 
with syphilitic products the venereal pus constitutes a 
virus which is doubly dangerous to the non-syphilitic 
organism. In such a case the venereal ulcer develops 
within a very short time and is followed later on by the 
appearance in the same situation of the initial syphilitic 
lesion with its characteristic infiltration and induration. 
In a syphilitic individual the venereal ulcer shows its 
usual characters ; although, according to some observers, 
the inflammatory reaction is aggravated by the excessive 
irritability inherent in all syphilitic tissues. 

The ulcer begins as a pustule resembling acne ; in 
twenty-four hours it becomes filled with pus and on the 
following day it bursts, discharging a mass of thick pus. 
The ulcer now looks as if it had been cut out with a 
punch, it has sharply defined edges and is surrounded by 
a narrow zone of inflammation. If a large wound, such 
as results from laceration for instance, becomes infected 
with venereal pus, the resulting ulcer exhibits a purulent 
floor with sharp, inflamed, suppurating walls. The latter 
are frequently undermined by the action of the pus and 
converted into detached shreds, more or less swollen and 
inflamed, and loosely adherent to the margin of the ulcer. 
The thick pus adheres to the surrounding surface and 
produces new ulcers which rapidly increase in size and, 



VENEREAL ULCERS. 91 

by coalescing with the original ulcer and with each other, 
form large, irregular ulcerating areas. If the pus is 
carried into a sebaceous or mucous gland, deep ulcers, as 
large as a pea and resembling furuncula, result. The 
pus is discharged through the duct of the disintegrated 
follicle some time before the walls break down, and a 
deep, eroded ulcer is exposed. Ulcers which are deep 
seated from the beginning frequently simulate an indura- 
tion before they break down and pus is discharged. If 
the inflamed tissues are at all hyperplastic, there is a per- 
ceptible increase in the resistance, but the sore never 
assumes the character of a typical syphilitic sclerosis. 
Induration is always a relative conception, even syphilitic 
ulcerations sometimes exhibit but a slight degree of 
induration. The rapid development, profuse suppura- 
tion, spread by infection to the surrounding parts, and 
the slight degree of induration are, however, suffi- 
ciently characteristic to establish the diagnosis of vene- 
real ulcer. 

The course is very simple if proper treatment is used 
and the pus can be removed. Within a week or two 
the floor of the ulcer ceases to secrete, and granulation- 
tissue is formed, the walls are reduced to the level of 
their surroundings, and cicatrization of the ulcer begins 
from one side or the other. If the case is carefully 
treated, the resulting scar is quite soft and but little de- 
pressed below the level of the skin. Sometimes, how- 
ever, owing to the seat, number, and extent of the vene- 
real ulcers and to numerous external conditions, the 
course as well as the termination of the disease is more 
serious. We have seen venereal ulcers in the foreskin, 
in the skin of the scrotum, groin, and surface of the 
opposite thigh, separated by more or less robust bridges 
of healthy skin, which constituted a grave condition. 
Under such circumstances the lymph-glands in the neigh- 
borhood are nearly always involved. 

Patients whose resisting power is low, or those who are 
enfeebled by other disease, suifer most from this condi- 



92 THE VENEREAL DISEASES. 

tion, as they lack the necessary energy to care for the 
ulcers properly from the beginning. 

It has already been stated that the genitalia are the 
most frequent seat of venereal ulcers. In the male the 
foreskin, the inner layer near the coronary sulcus, and 
particularly the frenum, which is often perforated at the 
base and reduced to a slender thread connecting the fore- 
skin with the head of the penis. The head itself is 
attacked less frequently, possibly because it contains 
fewer gland-ducts and is covered with smooth epidermis. 
In the female the most frequent sites are the labia majora, 
especially the posterior commissure, the vaginal orifice, 
and the remains of the hymen (fimbriae), the urethral 
orifice, the perineum, anus, vagina and vaginal portion of 
the uterus. 

In both sexes venereal ulcers are often found in the 
folds of the groin, on the inner aspect of the thighs, and 
on the symphysis. In addition we may mention the 
nose, mouth, tongue, nipple, navel, fingers, and other dis- 
tant parts covered with hair, which may become infected 
by accidental contact with the purulent secretions. 

If the above-mentioned characters are borne in mind — 
the circular shape, sharply defined edges, rapid develop- 
ment, and multiplicity — venereal ulcers can readily be 
distinguished from other processes occurring about the 
genitalia, such as acne, furuncula, etc. If there is no 
suspicion of sexual intercourse preceding the appearance 
of such processes, the diagnosis is quite easy. Moist 
papules in process of degeneration or covered with a 
diphtheritic secretion constitute the most frequent source 
of error. Again, however, the nature of the accompany- 
ing syphilitic symptoms, infiltration of neighboring 
lymph-glands, lesions of the skin and mucous membranes, 
the longer duration of syphilitic products, and, on the 
other hand, the suppuration in the glands which usually 
accompanies venereal ulcers of long standing, aiford a 
protection against error in diagnosis (Plates 61, 62). 

The complications which occur with venereal ulcers 



VENEREAL ULCERS. 93 

are chiefly due to the rapidly spreading inflammation 
which accompanies the ulceration. 

An ulcer situated at the edge of the foreskin often 
produces an inflammatory phimosis or paraphimosis. In 
either case gangrene may develop in the prepuce. A 
deep ulcer may produce a perforation in the frenum or 
even into the urethra. 

One of the most unpleasant complications is the inflam- 
mation of the lymphatics on the dorsum penis ; abscesses 
sometimes result and the skin over the abscesses is very 
prone to become gangrenous (Bubonulus Nisbethii). If 
there are several abscesses, the accumulated venereal pus 
under the skin may produce troublesome and tedious 
complications requiring the most energetic treatment 
(Plate 64). 

In the female we frequently observe ulcers in the 
shape of fissures between the fimbriae, deep ulcers in the 
ducts of Bartholin's glands, and destructive ulcerations 
about the urethral orifice, part of which is sometimes 
entirely lost by destruction of the upper wall. The 
posterior commissure is often the seat of large, deep 
ulcers, dangerous not only on account of their long dura- 
tion, but also because they are apt to spread toward the 
rectum. 

The frequent contamination with fecal matter and the 
painful stretching to which the parts about the anus are 
subjected tend to aggravate the condition in that situa- 
tion. The pain prevents the patient from fighting the 
ulceration as vigorously as he should, so that it often 
spreads to the rectum. 

One of the most important complications of the soft 
chancre is found in the inflammation of the local lymph- 
glands — bubo or adenitis. 

Adenitis rarely develops within the first two weeks 
after the appearance of the chancre ; usually it does not 
appear until the third or fourth week, or even later ; in 
some cases the glands begin to become inflamed after the 
ulcers have completely healed. This is apt to be the case 



94 THE VENEREAL DISEASES. 

when the ulcers are small and run their course without 
being noticed ; it is not possible in every case to refer the 
adenitis to the presence of a venereal ulcer. But the 
statement which has occasionally been made, that adenitis 
may develop without either the presence or previous 
existence of a venereal ulcer, through the uninjured skin, 
is not supported by the facts (primary buboes). 

The nearest group of lymph-glands is always in dan- 
ger of becoming involved, whatever may be the seat of 
the ulcers ; but, as they are most frequently found in or 
about the genitalia, we shall confine ourselves in the 
following to the lymph-glands of the inguinal region. 

As a rule, the glands of the same side are affected ; but 
occasionally the glands of the opposite side have been ob- 
served to suppurate, which is explained by the anatomical 
arrangement of the lymphatic vessels and their communi- 
cation with each other. 

One or more glands at first become slightly enlarged ; 
as the swelling and pain increase, especially if the part is 
freely used, a flat tumor with inflamed surface appears. 
If several glands are affected and the cellular tissue around 
them becomes swollen, an immovable mass of varying size 
develops, completely filling the inguinal region. Once 
the swelling has reached this stage there is little hope of 
resolution ; usually the tumor, which may be more or less 
prominent, begins to fluctuate and, unless surgical aid is 
rendered at once, the skin softens and undergoes liquefac- 
tion-necrosis. Sometimes gangrene supervenes, and the 
abscess discharges a thin, purulent material mixed with 
detritus. The condition is very painful and may be at- 
tended with fever and marked disturbances of the general 
health ; if left to itself after the contents of the abscess 
have been discharged, it persists for a long time until the 
cavity of the abscess clears up, the degenerated superficial 
portion is cast off', and scar-formation begins. In rare 
cases the gangrene spreads to such an extent that large 
areas of the skin and subcutaneous cellular tissue are 
destroyed, exposing the muscles of the inguinal region 



VENEREAL ULCERS. 95 

and even of the lower abdomen, as if they had been dis- 
sected for anatomical demonstration. Sometimes a multi- 
locular adenitis develops by the accumulation of pus in 
one spot and the undermining of the subcutaneous tissue 
and suppuration of the nearest gland. The day after one 
abscess has been opened another appears in its immediate 
proximity. In the days of conservative surgery patients 
would present themselves for treatment with six or eight 
such abscesses, all communicating with each other by 
fistulse and discharging thin, serous pus on pressure. 
They have been termed strumous buboes ; they contain 
enlarged and inflamed glands or the remains of glands 
embedded in a stroma of connective tissue which becomes 
very robust in advanced cases. We once saw such a case 
of neglected adenitis which resulted in putrefaction and 
discharge of the glands in the iliac region, followed by 
general sepsis. 

The diagnosis of such inflammatory tumors in the 
inguinal region can scarcely fail to be made if the rapid 
development and the presence of ulcers, or at least scars 
at the periphery (the genitalia, inner surfaces of the 
thighs, nates) are taken into consideration. The differen- 
tial diagnosis from scrofulous glandular abscesses, although 
it has no practical value, can easily be made by the gen- 
eral condition and the presence or absence of scrofulous 
signs in the skin and in the other glands of the body. 
Secondary abscesses from the pelvic region and diffuse 
phlegmon from osteal or periosteal disease can easily be 
distinguished by the nature of the secretions, the dura- 
tion of the process, and by careful examination into the 
condition of the bones and cartilages. There remain 
inguinal and femoral hernias, which only the most super« 
ficial examiner could mistake for adenitis. It is to be 
remembered, however, that a testicle which has become 
confined at the external abdominal ring may be so swollen 
and inflamed as to simulate an adenitis (see Plates 62, 63). 

The adenitis which accompanies the primary syphilitic 
lesion has been treated in its proper place. 



96 THE VENEREAL DISEASES. 

Treatment of Venereal Ulcers.— The contagious 
material is contained in the pus. The principal part of 
the treatment consists, therefore, in removing the pus and 
in preventing its being retained within the ulcer or con- 
veyed to surrounding portions of the skin. 

Cauterization, on account of its rapidity and efficiency 
in bringing about a thorough cure, has always stood in high 
repute as a treatment for venereal ulcers. Copper salts, 
carbolic acid, ferric chlorid, nitrate of silver, caustic lime, 
(quicklime) and the actual cautery itself have been em- 
ployed. The actual cautery, or the thermocautery which 
now takes its place, is still the sovereign remedy. Of the 
others, sulphate of copper, in a solution of 1 part of sulphate 
of copper to 4 parts of water is the best, as it cauterizes 
the ulcer and the surrounding infiltrated tissues without 
danger of injury to the healthy parts. The sulphate of 
copper is to be applied three or four times a day for some 
time. The wound is treated for a quarter of an hour at 
a time with pledgets of cotton dipped in the solution, the 
pledgets being changed several times. Finally a pledget 
is squeezed dry and allowed to remain on the ulcer. 
Cauterization with the solid stick is less satisfactory and 
more painful. The swelling which follows with the reac- 
tion must be controlled with compresses. In one day a 
dry, bluish eschar is formed which gradually comes away 
during the next two days. A dry, anemic wound remains, 
after which granulation and cicatrization must be induced 
by other means. 

Concentrated carbolic acid has a similar action ; it is 
applied with a cotton pledget fastened to the end of a 
wooden applicator like a brush. 

Silver nitrate, like copper sulphate, is better applied in a 
saturated solution than with the solid stick. Vienna paste l 
and chlorid of zinc cannot be used in all situations on ac- 
count of the danger to the surrounding parts. 

The best remedy of all is the Paquelin thermocautery. 

1 Caustic potash, 5 ; slaked lime, 6, mixed with alcohol to form a 
paste. 



VENEREAL ULCERS. 97 

Whatever form of cauterization be used, local anesthesia 
should first be induced by some of the customary drugs, 
cocain, etc. (If the Paquelin thermocautery is used, 
ethyl chlorid must not be employed.) 

If the seat of the ulcer is such that cauterization is not 
practicable (vaginal orifice, anus), it is replaced by care- 
ful applications of dusting-powder, ointments, or pastes, 
such as iodoform, dermatol, airol, salicylic acid, xeroform, 
etc. If such remedies are carefully and conscientiously 
applied, a few days will suffice to convert the ulcers into 
ordinary granulating wounds (stadium reparationis). 

In cases where the skin becomes undermined, in fistulas, 
in perforations of the frenum of the labia, the abscesses 
are first carefully disinfected and then opened with the 
knife and converted into open, granulating wounds. If, 
as occasionally happens in venereal ulcer, gangrene de- 
velops, a line of demarcation soon forms, the ulcer as 
such is destroyed, and, after the gangrenous slough is cast 
off, an ordinary wound without any specific character 
remains. 

The phagedenic ulcer is nothing but a rare subvariety 
of gangrene, with a tendency to rapid, purulent liquefac- 
tion. Such ulcers spread rapidly, have thick, irregular 
edges, and bleed very easily. The floor is covered with 
a dirty yellowish material ; the surrounding tissue is in- 
flamed and of a pale-red color. It is difficult to deter- 
mine the cause of phagedenic ulcers ; they usually occur 
in neglected cases, in anemic, debilitated individuals. The 
best treatment is the thermocautery, used under anesthesia. 

Treatment of the Adenitis. — The treatment of vene- 
real inflammation and abscess-formation in the glands 
varies somewhat for each individual case, hence we can 
give only a few general guiding principles. 

Since most cases of adenitis are not due to infection by 
the venereal pus which contains the virus, but represent 
simply a form of symptomatic buboes, the effect of rest 
and the application of moderately cold compresses of 
aluminum acetate solution, supplemented by an ice-bag 



98 THE VENEREAL DISEASES. 

on the outside, should first be tried. The time-honored 
remedy of painting with tincture of iodin and galls occa- 
sionally produces good results ; we do not, however, recom- 
mend a mere trial application of the tincture, as it only 
produces blisters and increases the pain. To have any 
effect the painting must be thorough ; then a scab will 
be formed on the same day and the progress of the inflam- 
mation will thus be arrested. If an abscess forms in spite 
of such energetic treatment, immediate interference is in- 
dicated. The mildest treatment of adenitis consists in 
puncture, evacuation of the abscess, and irrigation of the 
cavity with a 1 per cent, solution of argentic nitrate, the 
wound being afterward dressed with iodoform or sterilized 
gauze and the dressing held in place with a spica bandage. 
The dressing is changed the next day. If the secretion is 
still purulent, the abscess is again irrigated. After two 
days the dressing is again changed, and so on as long as 
the indications continue. 

If the abscesses are large and boggy and covered with 
a thin layer of skin, or if the roof has become gangrenous 
and the abscess bursts, the surrounding parts are first 
thoroughly cleansed, after which the hair is shaved, and 
the skin is again washed with ether and alcohol and 
irrigated with a lukewarm solution of sublimate. The 
attenuated covering is then removed, and the liquefied 
remains of glands and capsule, as well as the purulent 
inflammatory tissue between the glands, scraped out by 
one of the many methods known to modern surgery. 
This is the quickest way to effect a cure. The dressing 
can be left on for several days, to give the patient a 
chance to recover from the pain and shock of the ope- 
ration. 

The first-mentioned treatment for adenitis requires from 
ten days to three weeks to effect a cure ; the second, owing 
to the gravity of the cases in which it is employed, from 
five to eight weeks. 



VENEREAL ULCERS. 99 

Solutions for External Use. 

Ify. Hydrarg. chlor, corros., 0.5 (sjss) ; 

Spirit, vin., 

Aq. dest., ää. 100.0 (f£ij). 

S. : Dilute in 5 times the quantity of water. 
To be used as a lotion, with cotton pledgets. 

Iy. Acid, carbol., 4.0 (sj) ; 

Spirit, vin., 40.0 (fex) ; 

Aq. dest., 160.0 (ßv). 
S. : External use. 

!fy. Sodii borat., 10 to 200. 

S. : Lotion. 

^. Acid, salicy]., 2-4 to 200. 

S. : As above. 

3$-. Cupr. sulphat., 1 to 5. 

S. : For cauterization. 

Ifc. Cupr. sulphat., 2-5 to 100. 

S. : To be used in washing ulcers on the penis, pre- 
puce, etc., for from 5 to 10 minutes, and for 
dressing. 

Dusting-powders, to be used after the ulcers have been 
cleansed with the aboved-named solutions : 

Tfy. Iodoform, pulv., 10.0 (sijss). 

S. : Dusting-powder. 

Jfy. Iodoform, 1 to 5. 

With ether sulph. 
S. : For spraying. 

1^. Iodoform, 1 to 5 ; 

Vaselin. 
S. : Ointment. To be applied to the wound with gauze. 

1^. Iodoform gauze, 20 per cent. 

S. : For bandaging. 



100 THE VENEREAL DISEASES. 

1^. Xeroform, pur., 10.0 (3ijss). 

S. : Dusting-powder. 

]^. Dermatol, pulv., 10.0 (3\jss). 

S. : As above. 

]^. Aristol. 

S. : As above. 

]^. Airol. 

S. : As above. 

3^. Hydrarg. ammoniat., 0.5 (gr. viij) ; 
Vaselin, 15.0 (3jv). 

S. : Ointment for dressing. 

1^. Hydrarg. oxid. rubr., 0.1 (gr. jss) ; 
Vaselin, 10.0 (sijss). 

S. : Ointment for dressing torpid ulcers. 

1^. Arg. nitr. fus. 
S. : For touching proliferating ulcers after the use of 
iodoform and other remedies. 

1^. Arg. nitr., 1 to 15. 

S. : To be applied with pledgets of cotton instead of the 
solid stick. 

~fy. Bitum. phag. 5.0 (sjss) ; 

Gyps, (selenite, a native 

sulphate of calcium), 30.0 (3j). 
S. : Powdered gypsum. For extensive gangrenous wounds 
and neglected ulcers. 



GONORRHEA. 

Gonorrhea, or blennorrhea, is usually localized in the 
mucous membrane of the genitalia. In the majority of 
cases infection takes place by direct contact ; it may, 
however, be conveyed indirectly by polluted instruments, 
specula, clothing, bandages, towels, etc. 



GONORRHEA. 101 

The cause of this form of venereal catarrh is the 
gonococcus of Weisser, which has been demonstrated in 
the secretions, in the affected mucous membranes, and 
in other tissues, glands, and submucous tissues involved in 
the process. 

The results of numerous observations have established 
the fact that many other micro-organisms, whose special 
characters have not as yet been accurately described, exist 
normally and pathologically in the mucous membrane of 
the genitalia. In addition to the specific gonorrhea pro- 
duced by the gonococcus of Neisser, there are other catar- 
rhal affections of the genital mucous membrane in which 
these micro-organisms are also found. 

The limited scope of this work forbids a more detailed 
discussion of these conditions, and for the same reason 
our description of the gonorrheal processes themselves is 
perforce very brief and synoptic. 

It is a matter of clinical experience that contact of 
a healthy with a gonorrheal mucous membrane produces 
in from a few hours to three days alterations which sug- 
gest the probability, if not the certainty of the infectious 
nature of gonorrhea. 

The Symptoms consist of inflammation and hyper- 
emia of the affected mucous membrane, coupled with a 
discharge, at first mucous, but rapidly becoming purulent. 
The patient himself early becomes aware of the condi- 
tion on account of the swelling and subjective sense of 
burning. Gonorrhea is distinguished from all other forms 
of catarrh in the genital mucous membranes by its rapid 
spread and by the intense inflammation which marks the 
first week of its course. 

Acute urethral gonorrhea in the male (urethritis 
blenorrhagica) begins with a burning sensation, felt most 
during micturition ; the member is in a condition of 
semi-erection, the urethra itself is more or less increased 
in thickness and discharges at first a thin, watery pus, 
which later becomes thick and creamy, and in severe 
cases even mixed with blood. 



102 THE VENEREAL DISEASES. 

If the patient is so careless as to neglect this condition, 
the gonorrheal inflammation spreads to the membranous 
and prostatic portions of the urethra and eventually to 
the neck of the bladder, although there may be at first a 
partial abatement of the inflammatory and subjective 
symptoms. 

The intensity of the subjective symptoms increases 
with the spread and severity of the gonorrhea, the patient 
complains of pressure in the perineum and feels a con- 
stant desire to urinate (tenesmus) and, if the neck of the 
bladder is involved, is forced to urinate at intervals of 
half an hour to an hour. The inflammation itself and 
the pain which it produces, and which usually becomes 
worse at night, are sometimes very violent, so that the 
most phlegmatic individuals find them very distressing. 

No difficulty is experienced in demonstrating the char- 
acteristic gonococci within the cells of the urethral secre- 
tion in any stage of the disease. Method : spread a 
minute quantity of the secretion on a cover-slip, allow it 
to dry, and pass it rapidly through the flame of an alco- 
hol lamp two or three times (dry and fix), stain with car- 
bol fuchsin, gentian-violet, methyl-blue, etc., wash in 
water, dry with bibulous paper, and mount in Canada 
balsam. The gonococci are decolorized by Gram's method. 
Demonstration by means of cultures will not be discussed 
at this point. 

If the secretion is copious, the urine is turbid from 
admixture of pus and desquamated epithelium, which col- 
lect at the bottom of the vessel and form a dust-colored 
sediment. In order to diagnose a posterior urethritis, it 
is advisable to direct the patient to collect his morning 
urine in two separate portions. If the posterior part of 
the urethra is involved, both portions will be turbid. 

After a time both secretion and desquamation of the 
mucous membrane diminish. Either the process dis- 
appears from parts of the tube, or the secretion every- 
where diminishes in quantity ; at all events there is only 
a scant discharge of creamy, whitish material from 



GONORRHEA. 103 

the urethra. In this stage of the disease the discharge 
as every one knows, is most abundant after a night's rest ; 
the patient upon rising finds the opening of the urethra 
clogged, and, on squeezing, more or less pus is forced out 
(gontte militaire). The urine contains the characteristic 
gonorrheal shreds consisting of mucus, leukocytes, and epi- 
thelial cells from the urethra. At the same time there is an 
abatement in the subjective symptoms ; the patient feels 
much better and his complaint is less troublesome. Exces- 
sive indulgence in the pleasures of Bacchus or Venus at this 
period of chronic gonorrhea may bring on an acute 
exacerbation which may closely simulate a fresh infec- 
tion. 

The gonorrheal process may penetrate the mucous mem- 
brane and attack the submucosa, or, more frequently, 
spread along the ducts which empty into the urethra and 
involve the urethral glands themselves. The urethra be- 
comes studded with nodular outgrowths, irregularly dis- 
posed along its course, which may persist for some time, 
or break down and form periurethral abscesses. The 
inflammation in the submucosa sometimes spreads to the 
corpus cavernosum, where it produces tumors as large as, 
or larger than a walnut ; if the inflammation does not 
subside, large abscesses result. The symptoms of such 
an acute peri-urethritis are very marked : pain, fever, 
swelling, and distortion (bending) of the penis and fluc- 
tuation. 

Notwithstanding the great lengths of their ducts Cow- 
per's glands are also invaded by the gonorrheal process. 
The swelling begins behind and at the side of the bulb 
of the urethra, and is attended with moderate pain in the 
perineum ; with proper care on the part of the patient 
the swelling may disappear spontaneously. As, however, 
the causes which originally produced the inflammation in 
the gland-, such as forced irrigation, bougies, dancing, 
riding, and driving, do not, as a rule, cease immediately, 
the inflammation usually continues for some time. A 
large, painful, fluctuating tumor soon develops in the peri- 



104 THE VENEREAL DISEASES. 

neum. The patient has high fever and sometimes chills. 
The abscess will burst of its own accord ; but it is better 
not to wait for that event, as large quantities of gas and 
pus often accumulate in the cavity of the abscess and 
undermine the entire perineum as far as the anus. A 
speedy cure is affected by opening the abscess early ; large 
abscesses take from two to three months to heal and usu- 
ally leave a distortion of the urethra. 

The evil effects of gonorrhea show themselves much 
more frequently in the prostate gland than in any of the 
glandular structures which have been mentioned. Acute 
gonorrheal prostatitis constitutes a very grave complica- 
tion ; the patients are feverish, complain of difficulty in 
urination and defecation (dysuria and tenesmus), and con- 
stant burning pain in the rectum. On palpation per rec- 
tum one or both lobes of the prostate are found to be 
swollen, hard, and very sensitive to pressure. If the pro- 
cess goes on to suppuration, the accumulated pus can 
sometimes be felt as a soft mass within the swollen paren- 
chyma. In most cases it is discharged spontaneously 
through the urethra and leaves a flattened area in the 
prostate which can be distinctly felt. Sometimes the 
swelling does not suppurate, but results instead in a per- 
manent enlargement of the prostate. This is a very fre- 
quent concomitant of chronic gonorrhea, and may last 
as long as the patient lives, without his ever being aware 
of it. 

Another complication which is often overlooked by the 
patient is disease of the seminal vesicles. It may occur 
independently and run its course without being detected, 
or it may be accompanied by inflammation of the pros- 
tate and of the epididymis. 

The most frequent complication of all is gonorrheal epi- 
didymitis. It makes its appearance in the third week of 
the disease. Usually it is unilateral, but it may affect 
both sides, either simultaneously or one after the other. 
The testicle, which is partially enclosed in the epididymis, 
becomes swollen and painful. The spermatic cord, con- 



GONORRHEA. 105 

taining the blood-vessels and the vas deferens, become as 
large as a finger and can be felt as high up as the inguinal 
canal. The condition may be very painful and attended 
with high fever, so that the least susceptible patients are 
compelled to take to their beds. With antiphlogistic 
treatment and complete rest the pain and fever disappear 
in from five to eight days, leaving a moderate swelling 
and more or less induration of the epididymis, which sub- 
sides in from four to five weeks. The scrotum is always in- 
volved in the inflammatory process and adheres to the swoll- 
en epididymis, but usually only at the inferior pole on the 
affected side. In some cases of epididymitis there is quite 
a marked exudation into the tunica vaginalis propria {acute 
hydrocele), the pressure from which causes great pain. 
The exudate is sometimes so copious that it can be seen 
through the superficial layers of the scrotum at the supe- 
rior pole, as in chronic hydrocele. 

In rare instances the inflammation extends to the in- 
vesting membrane of the testicles ; the parenchyma of 
the glands themselves becoming involved during the 
inflammatory stage of the disease only. A very few of 
the many cases we have seen resulted in contraction of 
the connective tissue and atrophy of the gland-substance 
itself. 

In the female gonorrhea is more apt to involve the 
entire genito-urinary tract than in the male. Ignorance 
of the nature and significance of the disease on the part 
of the patients is largely responsible for this. The 
patients neglect to consult a physician, either because 
they do not realize the gravity of their condition or be- 
cause they dread exposure. The primary seat is the 
mucous membrane of the vulva, vagina, and urethra, 
which becomes inflamed and discharges a viscous, puru- 
lent secretion. The patient complains of burning pain 
during micturition. The inflammation soon attacks the 
labia; intertrigo and eczema develop in the skin and ag- 
gravate the burning and itching, or even cause actual 
pain. If treatment is still delayed, the gonorrheal pro- 



106 THE VENEREAL DISEASES. 

cess soon produces acute endometritis, salpingitis, peri- 
metritis, oophoritis, and even peritonitis. In this way 
chronic gonorrheal conditions frequently develop, having 
their principal seat in the uterine cavity and extending in 
both directions at the least exacerbation of the process. 
The patients are tortured by fever and various kinds of 
pain, varying according to the seat of the inflammation ; 
pains in the lower abdomen, dragging pains in the back 
and lumbar region, pains before menstruation, etc. 

Gonorrheal cystitis and 'pyelitis are very rare even in 
protracted cases of gonorrhea, although urethritis is both 
common and persistent. They are certainly much less 
frequent than in the male, where these complications con- 
stitute the most obstinate and, in their consequences, often 
the most serious sequela?. 

The complications discussed so far may be regarded as 
the direct extensions of the gonorrheal process. Of late 
years, however, numerous clinical observations and dis- 
coveries in bacteriology have demonstrated the occurrence 
of a metastasis of gonococci ; that is, an extension to re- 
mote organs by way of the blood- and lymph-channels. 
The most frequent of these complications is gonorrheal 
rheumatism. Usually the disease attacks but one joint 
(the knee) ; occasionally, however, several joints are in- 
volved at the same time. The cavity of the affected joint 
becomes filled with a serous exudate and considerably 
swollen ; there is a moderate rise in the temperature and 
a good deal of pain. The patient keeps the affected joint 
rigidly fixed, and is usually confined to his bed for some 
time in consequence. 

The joint-affection is sometimes combined with a teno- 
synovitis, or the latter may occur independently. The 
inflammation of the sheath is characterized by swelling, 
redness, and considerable pain in the affected tendons, the 
extremities involved being for the time disabled. 

The two last-named processes are very painful while 
they last, and interfere with the use of the extremities for 



GONORRHEA. 107 

some time ; they usually heal, however, without leaving 
any permanent alterations. 

Diseases of internal organs, such as endocarditis or 
pleuritis, as the direct consequences of gonorrhea are ex- 
tremely rare. On this account and because they so 
closely resemble diseases which depend on entirely dif- 
ferent etiological factors the diagnosis is very difficult ; 
after every other possibility has been excluded a pre- 
sumptive diagnosis may be made, if a gonorrheal condi- 
tion exists. 

The mucous membrane of the rectum often becomes in- 
volved in the gonorrheal process, especially in female 
patients, either by the gonorrheal pus dripping down 
from the vagina, or by direct infection through accidental 
contact with the penis during sexual intercourse. When 
gonorrhea attacks the rectum it is even more distressing 
and painful than when it is confined to the genitalis. 
Defecation is difficult and painful. The constant burning 
pain is so intense that the patients are as restless and 
excitable as if they were suffering from a severe illness. 
A purulent discharge mixed with blood and the remains 
of the broken-down mucous membrane flows from the 
anus. Energetic treatment is required ; the condition 
often lasts for weeks and may result in extensive cica- 
tricial contractions of the rectum. 

Condylomata Acuminata. 

Gonorrheal warts, venereal papillomata, must be men- 
tioned among the sequelae of gonorrhea. Although it is 
not definitely known that the gonorrheal virus in itself is 
capable of producing these papillomatous growths, their 
frequent occurrence in old, and even in acute cases of 
gonorrhea justifies the assumption that they are chiefly 
due to the constant irritation of the mucous membrane 
and external skin by the gonorrheal secretion. At first 
the surface of the mucous membrane presents a scarcely 
perceptible roughening, resembling plush or the surface 



108 THE VENEttEAL DISEASES. 

of a well-trimmed lawn. The process begins by a 
lengthening and swelling of the papillae. As the con- 
dylomata develop, the capillary loops in the papillae be- 
come longer and engorged with blood, and surrounded by 
a moderate round-celled infiltration. But the most con- 
spicuous changes are observed in the Malpighian layer, 
the greatly proliferated epithelium of which covers over 
the papillae and fills the intervals between them in thick 
layers. Owing to the constant maceration, the cells of 
the epidermis do not become horny, but undergo desqua- 
mation, so that the Malpighian layer is practically laid 
bare. At this stage the surface of the condylomata is 
moist and greasy to the touch. But the process is rarely 
limited to this cell-proliferation ; usually groups of swol- 
len papillae unite to form tumors as large as a pea or a 
hazelnut, rising from the base of the skin. Extensive 
growths of this kind present the appearance of cauli- 
flower, from the coalition of numerous papillomata ; the 
surface is ragged and deeply furrowed. The degener- 
ating epithelium and the whole mass of purulent material 
cause the patient much annoyance both on account of the 
offensive odor and the copious secretion. The capillary 
loops in the papillae are easily injured, so that the blood 
oozes out of the fissures between the papillomata if the 
tumor is subjected to any injury. 

In the male the condylomata occur most frequently 
on the inner surface of the foreskin, in the neck, and on 
the glans penis at the urethral orifice and sometimes as 
high up as the fossa navicularis. Large proliferations in 
the preputial sac may by their pressure produce inflam- 
mation and even necrosis of the foreskin. If the pro- 
liferations are very extensive, the differential diagnosis 
from carcinoma is often difficult ; it is based on the dura- 
tion of the process, the presence or absence of isolated 
papillomata near the periphery of the larger tumors and 
on the condition of the inguinal glands. 

Condylomata acuminata are more frequent in the fe- 
male. The vestibule, orifice of the urethra, vagina, and 



GONORRHEA. 109 

even the vaginal portion of the uterus are often covered 
with numerous proliferations, which by their rapid growth 
greatly annoy both patient and doctor. In addition the 
external skin of the female genitalia as far as the groin, 
and the perineum and region about the anus, may be the 
seat of such venereal papillomata; we have even seen 
tumors as large as the fist occupying this entire region. 

TREATMENT OF GONORRHEA AND ITS COMPLICATIONS. 

Acute Gonorrhea. 

During the stage of profuse purulent secretion the fol- 
lowing remedies are employed : 

(a) Internal. — 

1^. Mass. copaib., gtt. x. 

Dent. tal. dos. ad caps, gelatin., No. 1. 
S. : 4-6 capsules daily. 

1^. Ol. santali, gtt. x. 

Dent. tal. dos. ad caps, gelatin., No. 1. 
S. : 5-8 capsules daily. 

!$;. Pulv. cubeb., 

Extr. cubeb. alcohol., ää 5.00 3jss. — M. 

Ft. pil. No. 1. 

Consperge pulv. glycyrrhiz. 
S. : 3 pills 3 times a day. 

fy Pulv. cubeb., 30.00 (3j) ; 

Extr. acori calami, 

Extr. gentian., ää 1.00 (gr. xv). — M. 

S. : One knife-point after eating, 3 times a day. 

(b) For Injection. — During this period remedies are 
employed which are supposed, or known to possess disin- 
fectant and bactericidal qualities, but no astringent effect 
on the mucous membranes. 

1^. Ammon. sulphoichthyol., 1.5-2.00 (gr. xxiv-3ss) ; 

Aq. destill., 100.00 (ßiij). 

S. : To be injected 4 times a day. 



110 THE VENEREAL DISEASES. 

Iy. Argonin, 1.00-2.00 (gr. xv-3ss); 

Aq. destill., 100.00 (tgiij), — M. 

S. : To be injected 4 times a day. 

1^. Acid, tartar., 2 : 100. 

S. : To be injected 2 or 3 times a day ; retain for 10 
minutes. 

1^. Potass, hvpermang., 0.01 (gr. \) ; 

Aq. destill, 100.00 (fgij). — M. 

S. : To be injected 4 times a day. 

fy. Acid, boric, 2.00-4.00 (3B&-3J) ; 

Aq. destill., 100.00 (fgij). — M. 

S. : To be injected 4 times a day. 

At the end of the second, or the beginning of the third 
week astringents are employed. 

We recommend : 

1^. Zinci sulphat., 0.1-0.3 (gr. jss-gr. v) ; 

Aq. destill., 100.00 (ßij).— M. 

S. : To be injected 4 times a day. 

1^. Zinci sulphocarbol., 1.00-3.0 (gr. xv-gr. xlv); 

Aq. destill., 200.00 (gij).-M. 

S. : To be injected 4 times a day. 

Jfy. Arg. nitr., 0.10-0.50 (gr. jss-viij) ; 

Aq. destill., 200.00 (fsvj).— M. 

S. : To be injected 4 times a day. 

I^. Zinci sozoiodol., 1.00-5.00 (gr. xv-3Jss) ; 
Aq. destill., 200.00 (ßvj).— M. 

S. : To be injected 4 times a day. 

1^. Zinci sulphat., 0.5 (gr. viij) ; 

Plumb, acetat., 1.00 (gr. xv) ; 

Aq. destill., 200.00 (fgij). — M. 

S. : To be injected 4 times a day. Shake before using. 



GONORRHEA. Ill 

]^. Bismuth, subnitr., 5.00 (3Jss) ; 

Aq. destill., 200.00 (f §vj).— M. 

S. : To be injected 4 times a day. Shake before using. 

Chronic Gonorrhea. 

Injections of \ to 2 per cent, solutions of argentic 
nitrate, using Guyon's or Ultzmann's syringe. As high 
as 5 per cent, solutions of argentic nitrate are used for 
astringents. 

In addition, the posterior portion of the urethra, in the 
male, is to be irrigated with the lotions given for acute 
gonorrhea, using a Nelaton catheter or Ultzmann's irriga- 
tion catheter. 

Inflammation of the Neck of the Bladder (Cystitis 
Colli Vesicae). 

The patient must remain in bed ; the bowels must be 
kept open and the diet regulated. 
Internally : 

Jfy. Folior. uvea ursi ; 

Herniaria? glabrae, ää 25.00 (3ij). 

S. : Tea. 

fy. Decoct, sem. lini, 200.00 tflvj); 

Extr. laudani, 0.10 (gr. jss). 

S. : Take one tablespoonful. 

^. Salol, 10.00 (Sjss) ; 

Div. in dos. sequales, No. x. 
S. : 4 powders daily. 

1^. Terebinth, lig. ; 
Extr. cinchonas ; 

Magnes. carb., ää 5.0 (3Jss) ; 

Extr. et pulv. acori calami, ää q. s. ; 

F. pil. pond., 0.20 (gr. iij) ; 

No. c, consperge pulv. aromat. 
S. : 6-8 pills a day, 



112 THE VENEREAL DISEASES. 

Prostatitis. 

In the acute form lukewarm sitz-baths and applications 
of Arzberg's apparatus, either exclusively or alternating 
with suppositories : 

Ify. Morph, muriat., 0.10 (gr. jss) ; 

Olei theobr. q. s. u. f. suppos., No. x. 

Ij*. Extr. opii aquosi, 0.03 (gr. \) ; 

Olei theobr., 3.0 (gr. xlv) ; 

F. suppos. div. dos. vi. 
S. : Suppositories. 

fy. Extr. bellad., 0.10 (gr. jss) ; 

Olei theobromse q. s. u. f. suppos., No. x. 

If there is fluctuation, the abscess is opened from the 
rectum, using the proper surgical precautions. 

In chronic prostatitis suppositories of : 

I$>. Potass, iod., 1.00 (gr. xv) ; 

Iod. puri., 0.10 (gr. jss); 

Extr. laudan., 0.15 (gr. ij) ; 

Olei theobr. q. s. u. f. suppos., No. x. 
or 

Ify. Potass, iod., 1.0-1.5 (gr. xv-gr. xxiv) ; 

Solve in aq. dest., adde 

mucilag. semin. cydon., 150.0 (sivss). 
S. : To be taken as a clyster after 1 stool. 

In addition lukewarm sitz-baths. The bowels must be 
moved daily. Massage of the prostate also has a good 
effect. 

Epididymitis. 

In acute epididymitis compresses of ice-cold water or 
ice-bag. The bowels must be regulated. The pain is 
sometimes so great that the exhibition of opiates or a hy- 
podermatic injection of morphin becomes imperative. 



GONORRHEA. 113 

1^. Bismuth, subnitr., 10.00 (oijss) ; 

Extr. laudan., 0.10 (gr. jss). 

F. pulv. div. in dos. sequal., No. x. 
S. : 3 or 4 powders daily. 

After the period of severe pain is over, inunctions with 
the following preparations, to reduce the thickening in 
epididymis and spermatic cord : 



1^. Extr. bellad., 


1.00 (gr. xv); 


Ung. einer., 
Ung. simpl., 
, Ft. ung. 


ää 10.00 (3ijss). 


or painting with 




R. Tinct. iod., 




Tinct. gall., 


ää. 


or with : 




1^. Iod. puri., 
Potass, iod., 
Ung. emollient., 
Ft. ung. 


0.02 (gr.!); 
2.50 (gr. xl) ; 
25.00 (3ij). 



The patient should also be directed to wear a well-fitt- 
ing suspensory. Some prefer Fricke's adhesive-plaster 



Chronic Cystitis. 

Irrigation of the bladder with : 

1^. Acid boric, 50.0 (Sjss) ; 

Aq. dest., 1000.0 (Oij). 

Tfy. Potass hypermang., 1.0-3.0 (gr. xv-xlv) ; 
Aq. dest., 1000.0 (Oij). 

IJ*. Formalin, 1.0 (gr. xv) ; 

Aq. dest., 1000.0 (Oij). 



114 THE VENEREAL DISEASES. 

ly. Argent, nitr., 1.00-2.50 (gr. xv-xl); 

Aq. desk, 2000.00-1000.00 (Oiv to Oij). 

Balanitis and Balanoposthitis 

constitute a frequent complication of urethral gonorrhea 
in the male. They also occur without urethral disease. 
The best remedy is to wash the penis with antiseptic 
lotions ; if there is phimosis, the preputial sac should be 
irrigated with a 1-3 per cent, solution of copper sulphate 
or with a solution of aluminum acetate ; in addition the 
part should be dusted with : 

^. Dermatoli, 

Amyli, ää. 

S. : Dusting-powder. ^ 

1^. Acidi salicyl., 

Zinci oxydati, 1.0 (gr. xv) ; 

Amyli, ää 10.0 (sijss). 

Ft. p. 
S. : Dusting-powder. 

In the female, gonorrhea is usually localized in the 
vaginal portions of the urethra, in the cervix, and in 
Bartholin's glands. The urethral affection is treated ac- 
cording to the same principles as in the male. In order 
to remove the gonorrheal secretion which flows from the 
cervix and collects in the vagina, it is well to irrigate the 
part with a lukewarm 2 per cent, solution of soda, and 
after that with : 

I$*. Cupr. sulph., 1.0 (gr. xv) ; 

Aq. desk, 1000.0 (Oij). 

1^. Alumin. crud., 5.0 (§jss) ; 

Aq. desk, 1000.0 (Oij). 

1^. Hydrarg. chlor, corr., 1.0 (gr. xv) ; 

Aq. desk, 1000.0 (Oij) 



GONORRHEA. 115 

Ify. Ammon. sulphoichthyol., 10.0-20.0 (^ijss-Sv) ; 
Aq. dest., 1000.0 (Oij). 

To combat the cervical affection 1 per cent, solutions of 
argentic nitrate, tincture of iodin, and iodoform supposi- 
tories are used. The caustic substances are applied in 
solution with the uterine sound. In the intervals between 
the applications the vagina is packed with tampons dipped 
in the above-named substances, the tampons being fre- 
quently changed. 

Erosions of the labia are to be sprinkled with iodoform 
powder, or a tampon of iodoform gauze is introduced into 
the vagina as far as the orifice. 

In suppuration of the ducts of Bartholin's glands or of 
the glands themselves the abscess is to be opened, or the 
entire gland is extirpated. In catarrhal inflammation of 
the duct injections of about 1 per cent, argentic nitrate 
solution with AnePs syringe are to be recommended. 

Other complications of gonorrhea are treated according 
to the same principles as in the male. 

Hematuria. 

The patient is put to bed and the bowels are regulated. 

Jfy. Extr. haemostatic., 2.0-3.0 (gr. xxx-xlv) ; 
Aq. dest., 130.0 (f&j); 

Syr. acidi hydriodic, 20.0 (3v). 
S. : One tablespoonful every two hours. 

Gonorrheal Rheumatism. 

As a rule, preparations of salicylic acid have no effect. 
This peculiarity of the gonorrheal form of the disease 
may be of diagnostic value in doubtful cases. We re- 
commend potassium iodid in doses of 4 to 6 grs. per 
diem or 

fy. Sodii citrat., 5.0 (gr. x-3j) ; 

P. tal. dos. No. x. 
S. : 4 powders daily. 



116 TBE VENEREAL DISEASES. 

To allay the pain, the affected joint must be kept abso- 
lutely quiet and treated with compresses wet with alumi- 
num acetate (liquor Burow) or even with ice-bags. If 
the pain is very intense, especially at night, hypodermatic 
injections of morphin are the only effective remedy. 
After the inflammation has abated, the part may be 
dressed with a starched or silica bandage ; the patient 
feels more comfortable and is better able to change his 
position. If, after the bandage is removed, the part is 
still swollen, warm baths, massage, and painting with 
tincture of iodin are to be recommended. In order to 
prevent a more or less permanent stiffness, the patient 
should be anesthetized and the adhesions severed soon 
after the inflammatory symptoms have subsided. 

Condylomata Acuminata. 

Wash with antiseptic lotions (lysol 1 per cent., carbol 
2 per cent., copper sulphate 1-3 per cent.). Compresses 
of the alkaline earths or Burow's solution of aluminum 
acetate and dusting-powders : 

Ify. Plumb, acet. basic, crystallis. 
pulv., 
Alum. crud. pulveris, ää 10.0 (sijss) ; 

Dermatol., 30.0 (3j) ; 

Talci Venet. subtil, pulver., 50.0 (gxiij). 

If many gonorrheal warts are present, they should be 
thoroughly cleansed and moistened with water and then 
dusted with 

^. Resorcin, 

Amyl., ää 10.0 (sijss), 

after which they are to be isolated with gauze until the 
next dressing, which should take place after five or six 
hours. If the groups are large, it is best to scrape them 
out thoroughly with a curet, and cauterize the base with 
chromic acid (25-50 per cent.) or with sesquichlorid of 



GONORRHEA. 117 

iron. Very large proliferations must be excised with 
their base, leaving a funnel-shaped wound which is sewed 
up after the bleeding has stopped. Removal with the 
thermocautery is often the simplest and most radical 
operative measure. The wound is afterward treated ac- 
cording to the recognized principles of disinfection and 
dressed with an absorbent bandage. 



INDEX. 



Abscess-formation, 10 
Adenitis, Pis. 62, 63 

in primary stage, 9 

in secondary stage, 12 

in tertiary stage, 38 

in venereal ulcers, 93, 97 

treatment of, 74 
Albuminuria during mercurial 
treatment, 83 

in tertiarv stage, 53 
Alopecia, 21 ; Pis. 14, 14a, 20, 26, 

26a 
Amyloid disease of kidney, 53 
Arteritis, gummatous, 53 
Arthromeningitis, 36 
Astringents in acute gonorrhea, 110 
Asymmetry of tertiary lesions, 30 
Atrophy, smooth, of base of tongue, 

42 
Autopsies, Pis. 54, 54a, 58, 59 

Balanitis, 114 

Bartholin's glands, abscess of, PI. 
65 
in gonorrhea, 115 
in venereal ulcer, 93 
Baths. 81, 83, 84 

Brain, tertiary lesions of, arteries, 
61 
base, 63 
cerebellum, 62 
cortex, 61 

general pathology, 60 
meninges, 61 
Breast, gumma of, 57; Pis. 48a, 48b 
Bronchi, tertiary lesions of, 50 
Bubo, treatment of, 97 
in venereal ulcer, 93 
Bubonulus Xisbethii, 10, 93; PI. 64 
Burow's solution, 77, 116 

Carcinoma distinguished from 
gumma 42,45 



Care of mouth, 81, 83 
Caries in tertiary stage, 33, 35 
Carriers of infection, 7 
Catarrh, gastric, in tertiary stage, 46 
Cause of tertiary lesions, 29 
Cauterization of condylomata acu-. 
minata, 117 

of initial sclerosis, 73 

of venereal ulcers, 96 
Cavernitis, PI. 66 
Cerebellum, tertiary lesions of, 62 
Chancre, soft. See Ulcer, venereal. 
Channels of infection, 5 
Cheeks, secondary lesions, 26 

tertiary lesions, 45 

treatment of papules on, 75 
Cirrhosis, syphilitic, 48 
Classification of stages, 2 
Colles' law of immunity, 66 
Color-changes, 20 
Conditions of infection, 4 
Condylomata acuminata, 24, 108; 
Pis. 67-69 
treatment of, 116 
Cornea, syphilitic, 59 
Course of syphilitic disease (scheme 

of), 4 
Cowper's glands in gonorrhea, 103 
Cystitis, gonorrheal, 106 
treatment of, 111, 113 

Decoctum Zittmanni, 88 ; PI. 48a 
Degenerations in tertiary syphilis, 

31 
Diagnosis, errors in, 92, 95 
Ducrey-Krefting bacillus (venereal 

nicer), 90 
Dusting-powders for venereal ulcers, 

99 

Ear. tertiarv syphilis of, 45 
Ecthyma pustule, 18; Pis. 28, 29 
Eczema, mercurial, PI. o"; 

119 



120 



INDEX. 



Edema, indurative, 10, 24; Pis. 5, 

12 
Endarteritis obliterans, 53 
Endo-aortitis, 53 
Endocarditis, 51 

Epididymitis, gonorrheal, 104, 112 
Epilepsy, 62 

Epiphyses, disease of, 69 
Errors in diagnosis, 92, 95 
Eruptions during pregnancy, 25 
Erythema figuratum, Pis. 15, 16 
Esophagus, tertiary syphilis of, 45 
Excision of initial sclerosis, 73 
Eye (see also Hereditary syphilis), 57 

disease of cornea, 59 
of orbit, 58 

iritis, condylomatous, 60 ; PI. 43a 
plastic, 59 
serous, 59 

tarsitis, 59 ; PL 43b 

trachoma, 59 ; PI. 43b 

Fauces, secondary lesions of, 26 

treatment of, 76 
Fissures, PI. 31b 

treatment of, 78 
Fourth stage of syphilis, 28 
Frambesia, 21 ; Pis. 29, 29a, 44, 45 
Fracture, spontaneous, in osteo- 
myelitis, 36 

Gangrene in syphilitic tissues, 9 ; 
Pis. 20, 54, 54a 

in venereal ulcer, 93 

treatment of, 73 
Gastric catarrh in tertiary stage, 46 
Gingivitis, PI. 20, 54, 54a' 
Gonococcus of Neisser, 101 

method of demonstration, 102 
Gonorrhea, 100 ; PI. 66 

acute, in male, 101 
of female, 105 

astringents in, 110 

goutte militaire, 103 

rectum in, 107 

seminal vesicles in, 104 

symptoms of, 101 

treatment of, 109, 111 
Gonorrheal rheumatism, 106, 115 

shreds, 103 
Gummata, 32; Pis. 46-57 

cutaneous, 31 

distinguished from carcinoma, 
42, 45 



Gummata, distinguished from ini- 
tial sclerosis, 56 
from tubercular nodes, 45 

fibrous, 35 
Gummatous glossitis, 57 

hepatitis, 47 

myositis, 37 

osteomyelitis, 35 
Gums, secondary lesions of, 27 

tertiary lesions of, 45 

Headache, treatment of, 80 
Heart, endocarditis and pericardi- 
tis, 51 
myocarditis, fibrous, 51 
Hematuria, treatment of, 115 
Hemorrhages, cutaneous, 19 ; PI. 70 
Hemorrhagica syphilitica neonato- 
rum, 67 
Hepar lobatum, 48 
Hepatitis, gummatous, 47 

interstitial, 47 
Hereditary syphilis, 64 ; Pis. 58, 59, 
60 a-c 
eye symptoms, PI. 6a a-c 
immunity, 66 
infection, 64-66 
mortality in — table, 67 
pemphigus, 67 
prognosis of, 66 

syphilis hereditaria praecox, 67 
tarda, 69 

symptoms of, 71 
treatment of, 70 
Hutchinson's symptoms, 70 ; PI. 60 

a-c 
Hydrocele, acute, 105 
Hypodermatic methods, 85 

Immunity, 66 

Infantile acquired syphilis, 70 

Infection, channels of, 5 

germinal, 64 

mode and conditions, 1-5 

ovular, 65 

spermatic, 65 
Infective power of syphilitic 
lesions, 6, 25 
of venereal ulcers, 8, 90 
Initial forms, treatment of, 72 

sclerosis, 8 ; Pis. 1-11 

seats, 9, 73 
Injections in acute gonorrhea, 109 

hypodermatic, 85 



INDEX. 



121 



Insomnia, 11 

treatment of, 80 
Intermission period, 29 
Intestines in tertiary stage, 46 
Inunctions, mercurial, 82 
Iodids, use of, 86 
Iritis, condylomatous, 60 ; PI. 43a 

plastic, 59 

serous, 59 
Irritative stage, 3 

Jaundice, PI. 18 

Keratitis, interstitial, 59 
Kidney, amyloid disease of, 53 
in tertiary stage, 53 

Labarraque's solution, 77 
Larynx, tertiary syphilis of, 50 

treatment of, 76 
Latent stage, 29 
Leontiasis syphilitica, 34 
Leukoplasia, 15, 20, 42 ; Pis. 20, 24, 

24a, 36, 38, 41b, 42b, 53 
Lichenoid papules, 15 ; PI. 19 
Lips, secondary lesions, 26 

tertiary lesions, 45 

treatment of papules on, 75 
Liver, tertiary syphilis of, 47 
Lotions for venereal ulcers, 99 
Lungs, tertiary syphilis of, 51 
Lupus, syphilitic, 34 
Lymphangitis, 9 ; PI. 64 

Macular Syphilide, 13 ; PI. 14 

roseola, 14 ; PI. 13 
Malignant forms of syphilis, 4 
Mercurial stomatitis, 82 
Mercury, hypodermatic injections, 
85 

internal use of, 86 

inunctions, 82 
Molluscum contagiosum, PI. 71 
Mouth, care of, 81, 83 
Myelomalacia, 63 
Myelomeningitis, 63 
Myocarditis, fibrous, 51 
Myositis in tertiary stage, 33, 37 

Nasal cavity, tertiary syphilis of, 

50 
Navel, disease of, 68 
Necrosis, PI. 41a, 64 
Neuritis, 64 



Onychia, 23 ; PI. 32 

treatment of, 78 
Orbicular Syphilide, 16 ; PI. 16 
Orchitis, fibrous, 54 

gummatous, 55 
Osteomyelitis, 35 

spontaneous fracture in, 36 

Pachydermia syphilitica, 41 
Palate, secondary lesions, 26 

tertiary lesions, 43 
Pancreas, tertiary lesions, 48 
Papillomata, venereal, 25 
Papulse luxuriantes, 25 
Papular Syphilide, 15 ; Pis. 14, 14a, 
17, 19-26, 31-42, 58, 59 
irregular forms, 16 ; PL 22, 23 
lenticular papules, 15 
lichenoid papules, 15 ; PI. 19 
papulae nitentes, 16 ; PI. 25 
orbicular papules, 16 ; PI. 21 
treatment of, 77, 84 
Paraphimosis, 10 ; PL 63 

treatment of, 74 
Paronychia, 23 ; PL 32 

treatment of, 78 
Pemphigus, 6, 67 
Pericarditis, 51 
Periostitis, spontaneous, 35 
Pharynx, 44 
Phimosis, 10 ; PL 63 

treatment of, 73 
Pigmentation, 20 
Plenck's solution, 77 
Pregnancy, eruptions in, 25 
Primary lesion (see Initial sclerosis), 

8 
Prognosis in general, 3 
in hereditary syphilis, 66 
in synovitis, 37 
Prostate gland in gonorrhea, 104 
Prostatitis, treatment of, 112 
Psoriasis, 22; Pis. 12, 13, 14, 14a, 
26a, 30 
mucosa oris, 42 ; Pis. 41b, 42b 
treatment of, 78 
Pustular Syphilide, 17 ; Pis. 17, 27, 
28, 28a, 28b, 58, 59 
ecthyma pustule, 18; Pis. 28, 29 
major, 18 

minor or acneiform, 18 
variola syphilitica, 17 
vesicular Syphilide, 17 
Pyelitis, gonorrheal, 106 



122 



INDEX. 



Eectum in gonorrhea, 107 
Kheumatism, gonorrheal, 106 

treatment of, 115 
Eoseola, 14; Pis. 5, 11, 13 
Eupia, syphilitic, 18, 33 ; Pis. 44, 45, 
49 

Saddle-nose in hereditary syph- 
ilis, PL 60 a-c 
Scalp, diseases of, 21 ; Pis. 14, 14a, 
20, 26, 26a 
treatment of, 29 
Scar-formation in syphilides, 32 
Seborrhcea capitis, 21 
Seminal vesicles in gonorrhea, 104 
Spina ventosa, 36 

Spinal cord, tertiary syphilis of, 46 
Spleen, tertiary syphilis of, 40 
Stomach, catarrh of, in tertiary 

syphilis, 46 
Stomatitis, mercurial, 82 
Suprarenal body in tertiary syph- 
ilis, 41 
Syphilides, general character, (see 
Macular, Papular, Pustular, 
Gummata), 13 
scar-formation in, 32 
Syphilis, classification of stages of, 2 
first phenomena, 7 
"fourth," 28 
praecox, 67 ; Pis. 44, 45 
primary, 4 

adenitis, 10 
" phimosis and paraphimosis, 10 
secondary, 11 
adenitis, 12 
exanthemata, 13-18 
insomnia, 11 
prodromal symptoms, 11 
tertiary, 
asymmetry of lesions, 30 
cause of tertiary lesions, 29 
degenerations in, 31 
general character of lesions, 30 
infective power in, 6, 7, 25 
manner of occurrence, 30 
serpiginous ulcers, 31, 33 ; PL 
51 
Syphiloma, diffuse hypertrophic, 34 

Tabes, 64 

Tarsitis, 59 ; PL 43b 
Tendons, disease of, in tertiary 
syphilis, 38 



Tenosynovitis in gonorrheal rheu- 
matism, 106 
Testicles in tertiary syphilis, 54 
Thymus gland in hereditary syph- 
ilis, 68 
Thyroid gland in tertiary stage, 40 
Tongue, secondary lesions of, 27 
tertiary lesions of, 41, 43 
treatment of, 76 
Tonics, 81, 83 

Tonsils, leukoplasia of, Pis. 41b, 
42b, 43 
secondary lesions of, 26 
Tophi, 35 

Trachea in tertiary syphilis, 50 
Trachoma, 59 ; PL 43b 
Transmission in hereditary syph- 
ilis, 66 
of virus in initial forms, 72 
Treatment, 72 
antiseptic, 73 
chronic intermittent, 80 
expectant, 79 
fissures about the anus, 78 
general, 79, 83 
gonorrbea and complications, 109- 

111 
local, of secondary and tertiary 

forms, 75 
mercurial, 82 
venereal ulcers, 96 
Tubercular nodes distinguished 
from gummata, 45 

Ulcers, venereal, 89 ; Pis. 61, 62, 
63 

cauterization of, 96 

character of sore, 90 

complications, 93 

course, 91 

dusting-powders for, 99 

errors in diagnosis, 92, 95 

induration simulated, 90 

infective power, 8, 90 

lotions, 99 

seats, 91, 92, 93 

treatment of, 96 
Uterus, tertiary syphilis of, 57 

Variola syphilitica, 17 
Veins in tertiary stage, 53 
Vienna paste, 96 
Virus, transmission of, 72 
where found, 6, 7 



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Stewart and Lawrance's Medical Elec- 
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Sutton and Giles' Diseases of Women . . 26 
Thomas's Diet-List and Sick-Room Dietary24 
Thornton's Dose-Book and Manual of Pre- 
scription-Writing 26 

Van Valzah and Nisbet's Diseases of the 

Stomach 31 

Vierordt and Stviart's Medical Diagnosis . 12 

Warren's Surgical Pathology 11 

WolfFs Chemistry e8 

Wolff's Examination of Urine 28 



sr 



The works indicated thus (*) are sold by subscription {not by booksellers), usually 
through travelling solicitors, but they can be obtained direct from the office of publication 
(charges of shipment prepaid) by remitting the quoted prices. Full descriptive circulars of 
such works will be sent to any address upon application. 

All the other hooks advertised in this catalogue are commonly for sale by booksellers in 
all parts of the United States ; but any book will be sent by the publisher to any address 
(post-paid) on receipt of the price herein given. 



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allowed, regardless of the number of books purchased at one 
time. Prices on all works have been fixed extremely low, with 
the view to selling them strictly net and for cash. 

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attention, books being sent to any address in the United States, 
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CATALOGUE OF MEDICAL WORKS. 



For Sale by Subscription. 



AN AMERICAN TEXT-BOOK OF PHYSIOLOGY. Edited by 
William H. Howell, Ph. D., M. D., Professor of Physiology in the 
Johns Hopkins University, Baltimore, Md. One handsome octavo volume 
of 1052 pages, fully illustrated. Prices : Cloth, $6.00 net; Sheep or Half- 
Morocco, $7.00 net. 

This work is the most notable attempt yet made in America to combine in 
one volume the entire subject of Human Physiology by well-known teachers 
who have given especial study to that part of the subject upon which they write. 
The completed work represents the present status of the science of Physiology, 
particularly from the standpoint of the student of medicine and of the medical 
practitioner. 

The collaboration of several teachers in the preparation of an elementary text- 
book of physiology is unusual, the almost invariable rule heretofore having been 
for a single author to write the entire book. One of the advantages to be derived 
from this collaboration method is that the more limited literature necessary for 
consultation by each author has enabled him to base his elementary account 
upon a comprehensive knowledge of the subject assigned to him; another, and 
perhaps the most important, advantage is that the student gains the point of view 
of a number of teachers. In a measure he reaps the same benefit as would be 
obtained by following courses of instruction under different teachers. The 
different standpoints assumed, and the differences in emphasis laid upon the 
various lines of procedure, chemical, physical, and anatomical, should give the 
student a better insight into the methods of the science as it exists to-day. The 
work will also be found useful to many medical practitioners who may wish to 
keep in touch with the development of modern physiology. 

The main divisions of the subject-matter are as follows : General Physiology 
of Muscle and Nerve — Secretion — Chemistry of Digestion and Nutrition — 
Movements of the Alimentary Canal, Bladder, and Ureter— Blood and Lymph 
— Circulation — Respiration — Animal Heat — Central Nervous System — Special 
Senses — Special Muscular Mechanisms — Reproduction — Chemistry of the 
Animal Body. 

CONTRIBUTORS : 
HENRY P. BOWDITCH, M. D., 

Professor of Physiology, Harvard Med 
cal School. 

JOHN G. CURTIS, M. D., 



Professor of Physiology, Columbia Uni- 
versity, N. Y. (College of Physicians 
and Surgeons). 

HENRY H. DONALDSON, Ph.D., 

Head- Professor of Neurology, Univer- 
sity of Chicago. 

W. H. HOWELL, Ph. D., M. D., 

Professor of Physiology, Johns Hopkins 
University. 

FREDERIC S. LEE, Ph. D., 

Adjunct Professor of Physiology, Colum- 
bia University, N. Y. (College of 
Physicians and Surgeons). 



WARREN P. LOMBARD, M. D., 

Professor of Physiology, University of 
Michigan. 



GRAHAM LÜSK, Ph.D., 

Professor of Physiology, Yale Medical 
School. 

W. T. PORTER, M.D., 

Assistant Professor of Physiology, Har- 
vard Medical School. 

EDWARD T. REICHERT, M.D., 

Professor of Physiology, University of 
Pennsylvania. 

HENRY SEWALL, Ph.D., M. D., 

Professor of Physiology, Medical Depart 
ment, University of Denver. 



W. B. SAUNDERS' 



For Sale by Subscription. 



AN AMERICAN TEXT-BOOK OF APPLIED THERAPEU- 
TICS. For the Use of Practitioners and Students. Edited by 
James C. Wilson, M. D. } Professor of the Practice of Medicine and of 
Clinical Medicine in the Jefferson Medical College. One handsome octavo 
volume of 1326 pages. Illustrated. Prices: Cloth, $7.00 net; Sheep or 
Half- Morocco, $8.00 net. 

The arrangement of this volume has been based, so far as possible, upon 
modern pathologic doctrines, beginning with the intoxications, and following 
with infections, diseases due to internal parasites, diseases of undetermined 
origin, and finally the disorders of the several bodily systems — digestive, re- 
spiratory, circulatory, renal, nervous, and cutaneous. It was thought proper to 
include also a consideration of the disorders of pregnancy. 

The list of contributors comprises the names of" many who have acquired dis- 
tinction as practitioners and teachers of practice, of clinical medicine, and of 
the specialties. 

CONTRIBUTORS : 

Dr. I. E. Atkinson, Baltimore, Md. 
Sanger Brown, Chicago, I'll. 
John B. Chapin, Philadelphia, Pa. 
William C. Dabney, Charlottesville, Va. 
John Chalmers DaCosta, Philada., Pa. 
I. N. Danforth, Chicago, 111. 
John L. Dawson, Jr., Charleston, S. C. 
F. X. Dercum, Philadelphia, Pa. 
George Dock, Ann Arbor, Mich. 
Robert T. Edes, Jamaica Plain, Mass. 
Augustus A. Eshner, Philadelphia, Pa. 
J. T. Eskridge, Denver, Col. 
F. Forchheimer, Cincinnati, O. 
Carl Frese, Philadelphia, Pa. 
Edwin E. Graham, Philadelphia, Pa. 
John Guiteras, Philadelphia, Pa. 
Frederick P. Henry, Philadelphia, Pa. 
Guy Hinsdale, Philadelphia, Pa. 
Orville Horwitz, Philadelphia, Pa. 
W. W. Johnston, Washington, D. C. 
Ernest Laplace, Philadelphia, Pa. 
A. Laveran, Paris, France. 



Dr. James Hendrie Lloyd, Philadelphia, Pa. 
John Noland Mackenzie, Baltimore, Md. 
J. W. McLaughlin, Austin, Texas. 
A. Lawrence Mason, Boston, Mass. 
Charles K. Mills, Philadelphia, Pa. 
John K. Mitchell. Philadelphia, Pa. 
W. P. Northrup, New York City. 
William Osier, Baltimore, Md. 
Frederick A. Packard, Philadelphia, Pa. 
Theophilus Parvin, Philadelphia, Pa. 
Beaven Rake, London, England. 
E. O. Shakespeare, Philadelphia, Pa. 
Wharton Sinkler, Philadelphia. Pa. 
Louis Starr, Philadelphia, Pa. 
Henry W. Stelwagon, Philadelphia, Pa. 
James Stewart, Montreal, Canada. 
Charles G. Stockton, Buffalo, N. Y. 
James Tyson, Philadelphia, Pa. 
Victor C. Vaughan, Ann Arbor, Mich. 
James T. Whittaker, Cincinnati, O. 
J. C. Wilson, Philadelphia, Pa. 



The articles, with two exception's, are the contributions of American writers. 
Written from the standpoint of the practitioner, the aim of the work is to facili- 
tate the application of knowledge to the prevention, the cure, and the allevia- 
tion of disease. The endeavor throughout has been to conform to the title of 
the book — Applied Therapeutics — to indicate the course of treatment to be 
pursued at the bedside, rather than to name a list of drugs that have been used 
at one time or another. 

While the scientific superiority and the practical desirability of the metric 
system of weights and measures is admitted, it has not been deemed best to 
discard entirely the older system of figures, so that both sets have been given 
where occasion demanded. 



CATALOGUE OF MEDICAL WORKS. 



For Sale by Subscription. 

AN AMERICAN TEXT-BOOK OF OBSTETRICS. Edited by 
Richard C. Norris, M. D. ; Art Editor, Robert L. Dickinson, M. Ü. 
One handsome octavo volume of over iooo pages, with nearly 900 colored 
and half-tone illustrations. Prices : Cloth, $7.00; Sheep or Half-Morocco, 
$8.00. 

The advent of each successive volume of the series of the American Text- 
books has been signalized by the most flattering comment from both the Press 
and the Profession. The high consideration received by these text-books, and 
their attainment to an authoritative position in current medical literature, have 
been matters of deep international interest, which finds its fullest expression in 
the demand for these publications from all parts of the civilized world. 

In the preparation of the "American Text-Book of Obstetrics" the 
editor has called to his aid proficient collaborators whose professional prominence 
entitles them to recognition, and whose disquisitions exemplify Practical 
Obstetrics. While these writers were each assigned special themes for dis- 
cussion, the correlation of the subject-matter is, nevertheless, such as ensures 
logical connection in treatment, the deductions of which thoroughly represent 
the latest advances in the science, and which elucidate the best modern methods 
of procedure. 

The more conspicuous feature of the treatise is its wealth of illustrative 
matter. The production of the illustrations had been in progress for several 
years, under the personal supervision of Robert L. Dickinson, M. D., to whose 
artistic judgment and professional experience is due the most sumptuously 
illustrated work of the period. By means of the photographic art, combined 
with the skill of the artist and draughtsman, conventional illustration is super- 
seded by rational methods of delineation. 

Furthermore, the volume is a revelation as to the possibilities that may be 
reached in mechanical execution, through the unsparing hand of its publisher. 



CONTRIBUTORS : 



Dr. James C. Cameron. 
Edward P. Davis. 
Robert L. Dickinson. 
Charles Warrington Earle. 
James H. Etheridge. 
Henry J. Garrigues. 
Barton Cooke Hirst. 
Charles Jewett. 



Dr. Howard A. Kelly. 
Richard C. Norris. 
Chauncey D. Palmer. 
Theophilus Parvin. 
George A. Piersol. 
Edward Reynolds. 
Henry Schwarz. 



"At first glance we are overwhelmed by the magnitude of this work in several respects, 
viz. : First, by the size of the volume, then by the array of eminent teachers in this depart- 
ment who have taken part in its production, then by the profuseness and character of the 
illustrations, and last, but not least, the conciseness and clearness with which the text is ren- 
dered. This is an entirely new composition, embodying the highest knowledge of the art as 
it stands to-day by authors who occupy the front rank in their specialty, and there are many 
of them. We cannot turn over these pages without being struck by the superb illustrations 
which adorn so many of them. We are confident that this most practical work will find 
instant appreciation by practitioners as well as students." — New York Medical Times. 

Permit me to say that your American Text-Book of Obstetrics is the most magnificent 
medical work that 1 have ever seen. I congratulate you and thank you for this superb work, 
which alone is sufficient to place you first in the ranks of medical publishers. 

With profound respect I am sincerely yours, Alex. J. C. Skenb. 



W. B. SAUNDERS' 



For Sale by Subscription. 



AN AMERICAN TEXT-BOOK ON THE THEORY AND 
PRACTICE OF MEDICINE. By American Teachers. Edited 
by William Pepper, M. D., LL.D., Provost and Professor of the Theory 
and Practice of Medicine and of Clinical Medicine in the University of 
Pennsylvania. Complete in two handsome royal- octavo volumes of about 
iooo pages each, with illustrations to elucidate the text wherever necessary. 
Price per Volume : Cloth, $5.00 net; Sheep or Half-Morocco, $6.00 net. 



VOLFME I. CONTAINS: 



Hygiene. — Fevers (Ephemeral, Simple Con- 
tinued, Typhus, Typhoid, Epidemic Cerebro- 
spinal Meningitis, and Relapsing). — Scarla- 
tina, Measles, Röthein, Variola, Varioloid, 
Vaccinia, Varicella, Mumps, Whooping-cough, 
Anthrax, Hydrophobia, Trichinosis, Actino- 



mycosis, Glanders, and Tetanus. — Tubercu- 
losis, Scrofula, Syphilis, Diphtheria, Erysipe- 
las, Malaria, Cholera, and Yellow Fever. — 
Nervous, Muscular, and Mental Diseases etc. 



VOLUME II. CONTAINS: 



Urine (Chemistry and Microscopy). — Kid- 
ney and Lungs. — Air-passages (Larynx and 
Bronchi) and Pleura. — Pharynx, (Esophagus, 
Stomach and Intestines (including Intestinal 
Parasites), Heart, Aorta, Arteries and Veins. 



— Peritoneum, Liver,and Pancreas. — Diathet- 
ic Diseases (Rheumatism, Rheumatoid Ar- 
thritis, Gout, Lithsmia, and Diabetes.) — 
Blood and Spleen. — Inflammation, Embolism, 
Thrombosis, Fever, and Bacteriology. 



The articles are not written as though addressed to students in lectures, but 
are exhaustive descriptions of diseases, with the newest facts as regards Causa- 
tion, Symptomatology, Diagnosis, Prognosis, and Treatment, including a large 
number of approved formulae. The recent advances made in the study 
of the bacterial origin of various diseases are fully described, as well as the 
bearing of the knowledge so gained upon prevention and cure. The subjects 
of Bacteriology as a whole and of Immunity are fully considered in a separate 
section. 

Methods of diagnosis are given the most minute and careful attention, thus 
enabling the reader to learn the very latest methods of investigation without 
consulting works specially devoted to the subject. 



CONTRIBUTORS : 



Dr. J. S. Billings, Philadelphia. 
Francis Delafield, New York. 
Reginald H. Fitz, Boston. 
James W. Holland, Philadelphia. 
Henry M. Lyman, Chicago. 
William Osier, Baltimore. 



Dr. William Pepper, Philadelphia. 

W. Gilman Thompson, New York. 
W. H. Welch, Baltimore. 
James T. Whittaker, Cincinnati. 
James C. Wilson, Philadelphia. 
Horatio C. Wood, Philadelphia. 



" We reviewed the first volume of this work, and said : ' It is undoubtedly one of the best 
text-books on the practice of medicine which we possess.' A consideration of the second 
and last volume leads us to modify that verdict and to say that the completed work is, in our 
opinion, the best of its kind it has ever been our fortune to see. It is complete, thorough, 
accurate, and clear. It is well written, well arranged, well printed, well illustrated, and well 
bound. It is a model of what the modern text-book should be."— New York Medical Journal. 

" A library upon modern medical art. The work must promote the wider diffusion of 
sound knowledge." — American Lancet. 

" A trusty counsellor for the practitioner or senior student, on which he may implicitly 
rely." — Edinburgh Medical Journal. 



CATALOGUE OF MEDICAL WORKS. 



For Sale by Subscription. 



AN AMERICAN TEXT-BOOK OF SURGERY. Edited by Wil- 
liam W. Keen, M. D., LL.D., and J. William White, M. D., Ph. D. 
Forming one handsome royal-octavo volume of 1250 pages (10x7 inches), 
with 500 wood-cuts in text, and 37 colored and half-tone plates, many of 
them engraved from original photographs and drawings furnished by the 
authors. Prices: Cloth, $7.00 net; Sheep or Half- Morocco, #8.00 net. 

SECOND EDITION, REVISED AND ENLARGED, 

With a Section devoted to " The Use of the Röntgen Rays in Surgery." 

The want of a text-book which could be used by the practitioner and at the 
same time be recommended to the medical student has been deeply felt, espe- 
cially by teachers of surgery; hence, when it was suggested to a number of 
these that it would be well to unite in preparing a text-book of this description, 
great unanimity of opinion was found to exist, and the gentlemen below named 
gladly consented to join in its production. While there is no distinctive Amer- 
ican Surgery, yet America has contributed very largely to the progress of modern 
surgery, and among the foremost of those who have aided in developing this art 
and science will be found the authors of the present volume. All of them are 
teachers of surgery in leading medical schools and hospitals in the United States 
and Canada. 

Especial prominence has been given to Surgical Bacteriology, a feature which 
is believed to be unique in a surgical text-book in the English language. Asep- 
sis and Antisepsis have received particular attention. The text is brought well 
up to date in such important branches as cerebral, spinal, intestinal, and pelvic 
surgery, the most important and newest operations in these departments being 
described and illustrated. 

The text of the entire book has been submitted to all the authors for their 
mutual criticism and revision — an idea in book-making that is entirely new and 
original. The book as a whole, therefore, expresses on all the important sur- 
gical topics of the day the consensus of opinion of the eminent surgeons who 
have joined in its preparation. 

One of the most attractive features of the book is its illustrations. Very 
many of them are original and faithful reproductions of photographs taken 
directly from patients or from specimens. 



CONTRIBUTORS : 



Dr. Charles H. Burnett, Philadelphia. 
Phineas S. Conner, Cincinnati. 
Frederic S. Dennis, New York. 
William W. Keen, Philadelphia. 
Charles B. Nancrede, Ann Arbor, Mich. 
Roswell Park, Buffalo, N. Y. 
Lewis S. Pilcher, New York. 



Dr. Nicholas Senn, Chicago. 

Francis J. Shepherd, Montreal, Canada. 

Lewis A. Stimson, New York. 

William Thomson, Philadelphia. 

J. Collins Warren, Boston. 

J. William White, Philadelphia. 



If this text-book is a fair reflex of the present position of American surgery, we must 
admit it is of a very high order of merit, and that English surgeons will have to look very 
carefully to their laurels if they are to preserve a position in the van of surgical practice."— 
London Lancet, 



W. B. SAUNDERS' 



For Sale toy Subscription, 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, MEDICAL 
AND SURGICAL, for the use of Students and Practitioners. 
Edited by J. M. Baldy, M. D. Forming a handsome royal-octavo volume, 
with 360 illustrations in text and 37 colored and half-tone plates. Prices : 
Cloth, $6.00 net; Sheep or Half-Morocco, $7.00 net. 

In this volume all anatomical descriptions, excepting those essential to a clear 
understanding of the text, have been omitted, the illustrations being largely de- 
pended upon to elucidate the anatomy of the parts. This work, which is 
thoroughly practical in its teachings, is intended, as its title implies, to be a 
working text-book for physicians and students. A clear line of treatment has 
been laid down in every case, and although no attempt has been made to dis- 
cuss mooted points, still the most important of these have been noted and ex- 
plained. The operations recommended are fully illustrated, so that the reader, 
having a picture of the procedure described in the text under his eye, cannot fail 
to grasp the idea. All extraneous matter and discussions have been carefully 
excluded, the attempt being made to allow no unnecessary details to cumber 
the text. The subject-matter is brought up to date at every point, and the 
work is as nearly as possible the combined opinions of the ten specialists who 
figure as the authors. 

The work is well illustrated throughout with wood-cuts, half-tone and 
colored plates, mostly selected from the authors' private collections. 



CONTRIBUTORS : 



Dr. Henry T. Byford. 
JohnM. Baldy. 
Edwin Cragin. 
). H. Etheridge. 
William Goodell. 



Dr. Howard A. Kelly. 
Florian Krug. 
E. E. Montgomery. 
William R. Pryor. 
George M. Tuttle. 



"The most notable contribution to gynecological literature since 1887, .... and the most 
complete exponent of gynecology which we have. No subject seems to have been neglected, 
.... and the gynecologist and surgeon, and the general practitioner who has any desire 
to practise diseases of women, will find it of practical value. In the matter of illustrations 
and plates the book surpasses anything we have seen." — Boston Medical and Surgical 
Journal. 

"A valuable addition to the literature of Gynecology. The writers are progressive, 
aggressive, and earnest in their convictions." — Medical News, Philadelphia. 

" A thoroughly modern text-book, and gives reliable and well-tempered advice and in- 
struction." — Edinburgh Medical Journal. 

" The harmony of its conclusions and the homogeneity of its style give it an individuality 
which suggests a single rather than a multiple authorship." — Annals of Surgery. 

" It must command attention and respect as a worthy representation of our advanced 
clinical teaching." — American Journal of Medical Sciences. 



CATALOGUE OF MEDICAL WORKS. 



For Sale by Subscription. 



AN AMERICAN TEXT-BOOK OF THE DISEASES OF CHIL- 
DREN. By American Teachers. Edited by Louis Starr, M. D., 
assisted by Thompson S. Westcott, M. D. In one handsome royal-8vo 
volume of 1190 pages, profusely illustrated with wood-cuts, half-tone and 
colored plates. Net Prices : Cloth, #7.00 ; Sheep or Half-Morocco, $8.00. 

The plan of this work embraces a series of original articles written by some 
sixty well-known podiatrists, representing collectively the teachings of the most 
prominent medical schools and colleges of America. The work is intended t© 
be a practical book, suitable for constant and handy reference by the practi- 
tioner and the advanced student. 

One decided innovation is the large number of authors, nearly every article 
being contributed by a specialist in the line on which he writes. This, while 
entailing considerable labor upon the editors, has resulted in the publication of 
a work thoroughly new and abreast of the times. 

Especial attention has been given to the latest accepted teachings upon the 
etiology, symptoms, pathology, diagnosis, and treatment of the disorders of chil- 
dren, with the introduction of many special formulae and therapeutic procedures. 

Special chapters embrace at unusual length the Diseases of the Eye, Ear, 
Nose and Throat, and the Skin ; while the introductory chapters cover fully the 
important subjects of Diet, Hygiene, Exercise, Bathing, and the Chemistry of 
Food. Tracheotomy, Intubation, Circumcision, and such minor surgical pro- 
cedures coming within the province of the medical practitioner are carefully 
considered. 

CONTRIBUTORS : 



S. S. Adams, Washington. 
John Ashhurst, Jr., Philadelphia. 
A. D. Blackader, Montreal, Canada. 
Dillon Brown, New York. 
Edward M. Buckingham, Boston. 
Charles W. Burr, Philadelphia. 
W. E. Casselberry, Chicago. 
Henry Dwight Chapin, New York. 
W. S. Christopher, Chicago. 
Archibald Church, Chicago. 
Floyd M. Crandall, New York. 
Andrew F. Currier, New York. 
Roland G. Curtin, Philadelphia 
J. M. DaCosta, Philadelphia. 
I. N. Danforth, Chicago. 
Edward P. Davis, Philadelphia. 
John B. Deaver, Philadelphia. 
G. E. de Schweinitz, Philadelphia. 
John Doming, New York. 
Charles Warrington Earle, Chicago. 
Wm. A. Edwards, San Diego, Cal. 
F. Forchheimer, Cincinnati. 
J. Henry Fruitnight, New York. 
Landon Carter Gray, New York. 
J. P. Crozer Griffith, Philadelphia. 
W. A. Hardaway. St. Louis. 
M. P Hatfield, Chicago. 
Barton Cooke Hirst, Philadelphia. 
H. Illoway, Cincinnati. 
Henry Jackson, Boston. 
Charles G. Jennings, Detroit. 
Henry Koplik. New York. 



Dr. Thomas S. Latimer, Baltimore. 
Albert R. Leeds, Hoboken, N. J. 
J. Hendrie Lloyd, Philadelphia. 
George Roe Lockwood, New York. 
Henry M. Lyman, Chicago. 
Francis T. Miles, Baltimore. 
Charles K. Mills, Philadelphia. 
John H. Musser, Philadelphia. 
Thomas R. Neilson, Philadelphia. 
W. P. Northrup, New York. 
William Osier, Baltimore. 
Frederick A. Packard, Philadelphia. 
William Pepper, Philadelphia. 
Frederick Peterson, New York. 
W. T. Plant, Syracuse, New York. 
William M. Powell, Atlantic City. 
B. Alexander Randall, Philadelphia. 
Edward O. Shakespeare, Philadelphia 
F. C. Shattuck, Boston. 
J. Lewis Smith, New York. 
Louis Starr, Philadelphia. 
M. Allen Starr, New York. 
J. Madison Taylor, Philadelphia. 
Charles W. Townsend, Boston. 
James Tyson, Philadelphia. 
W. S. Thayer, Baltimore. 
Victor C. Vaughan, Ann Arbor, Mich 
Thompson S. Westcott, Philadelphia. 
Henry R. Wharton, Philadelphia. 
J. William White, Philadelphia. 
J. C. Wilson, Philadelphia. 



IO w. B. SAUNDERS' 



A NEW PRONOUNCING DICTIONARY OF MEDICINE, with 
Phonetic Pronunciation, Accentuation, Etymology, etc. By John 
M. Keating, M. D., LL.D., Fellow of the College of Physicians of Phila- 
delphia ; Vice-President of the American Pediatric Society ; Ex-President 
of the Association of Life Insurance Medical Directors ; Editor " Cyclo- 
paedia of the Diseases of Children," etc. ; and Henry Hamilton, author 
of " A New Translation of Virgil's iEneid into English Rhyme ;" co- 
author of "Saunders' Medical Lexicon," etc.; with the Collaboration of 
J. Chalmers DaCosta, M. D., and Frederick A. Packard, M. D. 
With an Appendix containing important Tables of Bacilli, Micrococci, 
Leucomaines, Ptomaines, Drugs and Materials used in Antiseptic Sur- 
gery, Poisons and their Antidotes, Weights and Measures, Thermometric 
Scales, New Official and Unofficial Drugs, etc. One very attractive volume 
of over 800 pages. Second Revised Edition. Prices : Cloth, $5.00 net ; 
Sheep or Half-Morocco, $6.00 net; with Denison's Patent Ready-Refer- 
ence Index ; without patent index, Cloth, $4.00 net ; Sheep or Half- 
Morocco, $5.00 net. 

PROFESSIONAL OPINIONS. 

" I am much pleased with Keating's Dictionary, and shall take pleasure in recommending 
it to my classes." 

Henry M. Lyman, M. D., 
Professor 0/ Principles and Practice of Medicine, Rush Medical College, Chicago, III. 

" I am convinced that it will be a very valuable adjunct to my study-table, convenient in 
size and sufficiently full for ordinary use." 

C. A. Lindsley, M. D., 
Professor of Theory and Practice of Medicine, Medical Dept. Yale University ; 

Secretary Connecticut State Board of Health, New Haven, Conn, 



AUTOBIOGRAPHY OF SAMUEL D. GROSS, M. D., Emeritus Pro- 
fessor of Surgery in the Jefferson Medical College of Philadelphia, with 
Reminiscences of His Times and Contemporaries. Edited by his sons, 
Samuel W. Gross, M. D., LL.D., late Professor of Principles of Surgery 
and of Clinical Surgery in the Jefferson Medical College, and A. Haller 
Gross, A. M., of the Philadelphia Bar. Preceded by a Memoir of Dr. 
Gross, by the late Austin Flint, M. D., LL.D. In two handsome volumes, 
each containing over 400 pages, demy 8vo, extra cloth, gilt tops, with fine 
Frontispiece engraved on steel. Price per Volume, $2.50 net. 
This autobiography, which was continued by the late eminent surgeon until 
within three months of his death, contains a full and accurate history of his 
early struggles, trials, and subsequent successes, told in a singularly interesting 
and charming manner, and embraces short and graphic pen-portraits of many 
of the most distinguished men — surgeons, physicians, divines, lawyers, states- 
men, scientists, etc. — with whom he was brought in contact in America and in 
Europe ; the whole forming a retrospect of more than three-quarters of a century. 



CATALOGUE OF MEDICAL WORKS. II 

SURGICAL PATHOLOGY AND THERAPEUTICS. By John 
Collins Warren, M. D., LL.D., Professor of Surgery, Medical Depart- 
ment Harvard University; Surgeon to the Massachusetts General Hospital, 
etc. A handsome octavo volume of 832 pages, with 136 relief and litho- 
graphic illustrations, ^ of which are printed in colors, and all of which 
were drawn by William J. Kaula from original specimens. Prices : Cloth, 
$6.00 net ; Half-Morocco, $7.00 net. 

" The volume is for the bedside, the amphitheatre, and the ward. It deals 
with things not as we see them through the microscope alone, but as the prac- 
titioner sees their effect in his patients ; not only as they appear in and affect 
culture-media, but also as they influence the human body ; and, following up 
the demonstrations of the nature of diseases, the author points out their logical 
treatment." (New York Medical Journal). " It is the handsomest specimen 
of book-making * * * that has ever been issued from the American medical 
press " (American Journal of the Medical Sciences, Philadelphia). 

Without Exception, the Illustrations are the Best ever Seen in a 
Work of this Kind. 

"A most striking and very excellent feature of this book is its illustrations. Without ex- 
ception, from the point of accuracy and artistic merit, they are the best ever seen in a work 
of this kind. * * * Many of those representing microscopic pictures are so perfect in their 
coloring and detail as almost to give the beholder the impression that he is looking down the 
barrel of a microscope at a well-mounted section." — Annals of Surgery, Philadelphia. 

PATHOLOGY AND SURGICAL TREATMENT OF TUMORS. 

By N. Senn, M. D., Ph. D., LL. D., Professor of Practice of Surgery and 
of Clinical Surgery, Rush Medical College ; Professor of Surgery, Chicago 
Polyclinic ; Attending Surgeon to Presbyterian Hospital ; Surgeon-in-Chief, 
St. Joseph's Hospital, Chicago. One volume of 710 pages, with 515 
engravings, including full-page colored plates. Prices: Cloth, $6.00 net; 
Half-Morocco, $7.00 net. 

Books specially devoted to this subject are few, and in our text-books and 
systems of surgery this part of surgical pathology is usually condensed to a de- 
gree incompatible with its scientific and clinical importance. The author spent 
many years in collecting the material for this work, and has taken great pains 
to present it in a manner that should prove useful as a text-book for the student, 
a work of reference for the busy practitioner, and a reliable, safe guide for the 
surgeon. The more difficult operations are fully described and illustrated. More 
than one hundred of the illustrations are original, while the remainder were 
selected from books and medical journals not readily accessible. 

" The most exhaustive of any recent book in English on this subject. It is well illus- 
trated, and will doubtless remain as the principal monograph on the subject in our language 
for some years. The book is handsomely illustrated and printed, .... and the author has 
given a notable and lasting contribution to surgery." — Jotirnal of American Medical Asso- 
ciation, Chicago. 



12 W. B. SAUNDERS 1 



MEDICAL DIAGNOSIS. By Dr. Oswald Vierordt, Professor of 
Medicine at the University of Heidelberg. Translated, with additions, 
from the Second Enlarged German Edition, with the author's permission, 
by Francis H. Stuart, A. M., M. D. Third and Revised Edition. In 
one handsome royal-octavo volume of 700 pages, 178 fine wood-cuts in 
text, many of which are in colors. Prices : Cloth, $4.00 net ; Sheep or 
Half- Morocco, $5.00 net. 

In this work, as in no other hitherto published, are given full and accurate 
explanations of the phenomena observed at the bedside. It is distinctly a clin- 
ical work by a master teacher, characterized by thoroughness, fulness, and accu- 
racy. It is a mine of information upon the points that are so often passed over 
without explanation. Especial attention has been given to the germ-theory as a 
factor in the origin of disease. 

This valuable work is now published in German, English, Russian, and 
Italian. The issue of a third American edition within two years indicates the 
favor with which it has been received by the profession. 

THE PICTORIAL ATLAS OF SKIN DISEASES AND SYPHI- 
LITIC AFFECTIONS. (American Edition.) Translation from 
the French. Edited by J. J. Pringle, M. B., F. R. C. P., Assistant Phy- 
sician to, and Physician to the department for Diseases of the Skin at, the 
Middlesex Hospital, London. Photo-lithochromes from the famous models 
of dermatological and syphilitic cases in the Museum of the Saint-Louis 
Hospital, Paris, with explanatory wood-cuts and letter-press. Jn 12 Parts, 
at $3.00 per Part. Parts I to 8 now ready. 

"The plates are beautifully executed." — Jonathan Hutchinson, M. D. (London 
Hospital). 

" The plates in this Atlas are remarkably accurate and artistic reproductions of typical 
examples of skin disease. The work will be of great value to the practitioner and student." 
— William Anderson, M. D. (St. Thomas Hospital). 

" If the succeeding parts of this Atlas are to be similar to Part 1, now before us, we have 
no hesitation in cordially recommending it to the favorable notice of our readers as one of 
the finest dermatological atlases with which we are acquainted." — Glasgow Medical Journal, 
Aug., 1895. 

" Of all the atlases of skin diseases which have been published in recent years, the present 
one promises to be of greatest interest and value, especially from the standpoint of the 
general practitioner." — American Medico-Surgical Bulletin, Feb. 22, 1896. 

" The introduction of explanatory wood-cuts in the text is a novel and most important 
feature which greatly furthers the easier understanding of the excellent plates, than which 
nothing, we venture to say, has been seen better in point of correctness, beauty, and general 
merit." — Neiu York Medical Journal ', Feb. 15, 1896. 

" An interesting feature of the Atlas is the descriptive text, which is written for each picture 
by the physician who treated the case or at whose instigation the models have been made. 
We predict for this truly beautiful work a large circulation in all parts of the medical world 
where the names St. Louis and Baretta have preceded it." — Medical Record, N. Y., Feb. 1, 
1896. 



CATALOGUE OF MEDICAL WORKS. 1 3 

PRACTICAL POINTS IN NURSING. For Nurses in Private 
Practice. By Emily A. M. Stoney, Graduate of the Training-School 
for Nurses, Lawrence, Mass. ; Superintendent of the Training-School for 
Nurses, Carney Hospital, South Boston, Mass. 456 pages, handsomely 
illustrated with 73 engravings in the text, and 9 colored and half-tone 
plates. Cloth. Price, #1.75 net. 

SECOND EDITION, THOROUGHLY REVISED. 

In this volume the author explains, in popular language and in the shortest 
possible form, the entire range of private nursing as distinguished from hospital 
nursing, and the nurse is instructed how best to meet the various emergencies of 
medical and surgical cases when distant from medical or surgical aid or when 
thrown on her own resources. 

An especially valuable feature of the work will be found in the directions to 
the nurse how to improvise everything ordinarily needed in the sick-room, where 
the embarrassment of the nurse, owing to the want of proper appliances, is fre- 
quently extreme. 

The work has been logically divided into the following sections : 

I. The Nurse : her responsibilities, qualifications, equipment, etc. 
II. The Sick-Room : its selection, preparation, and management. 

III. The Patient : duties of the nurse in medical, surgical, obstetric, and gyne- 

cologic cases. 

IV. Nursing in Accidents and Emergencies. 
V. Nursing in Special Medical Cases. 

VI. Nursing of the New-born and Sick Children. 
VII. Physiology and Descriptive Anatomy. 

The Appendix contains much information in compact form that will be found 
of great value to the nurse, including Rules for Feeding the Sick; Recipes for 
Invalid Foods and Beverages; Tables of Weights and Measures; Table for 
Computing the Date of Labor; List of Abbreviations ; Dose-List; and a full 
and complete Glossary of Medical Terms and Nursing Treatment. 

"This is a well-written, eminently practical volume, which covers the entire range of 
private nursing as distinguished from hospital nursing, and instructs the nurse how best to 
meet the various emergencies which may arise and how to prepare everything ordinarily 
needed in the illness of her patient." — American Journal of Obstetrics and Diseases of 
Women and Children, Aug., 1896. 

A TEXT-BOOK OF BACTERIOLOGY, including the Etiology and 
Prevention of Infective Diseases and an account of Yeasts and Moulds, 
Haematozoa, and Psorosperms. By Edgar M. Crookshank, M. B., Pro- 
fessor of Comparative Pathology and Bacteriology, King's College, London. 
A handsome octavo volume of 700 pages, with 273 engravings in the text, 
and 22 original and colored plates. Price, $6.50 net. 

This book, though nominally a Fourth Edition of Professor Crookshank's 
" Manual of Bacteriology," is practically a new work, the old one having 
been reconstructed, greatly enlarged, revised throughout, and largely rewritten, 
forming a text-book for the Bacteriological Laboratory, for Medical Ofhcers of 
Health, and for Veterinary Inspectors. 



I 

14 W. B. SAUNDERS' 



A TEXT-BOOK OF HISTOLOGY, DESCRIPTIVE AND PRAC- 
TICAL. For the Use of Students. By Arthur Clarkson, M. B., 
C. M., Edin., formerly Demonstrator of Physiology in the Owen's College, 
Manchester; late Demonstrator of Physiology in the Yorkshire College, 
Leeds. Large 8vo, 554 pages, with 22 engravings in the text, and 174 
beautifully colored original illustrations. Price, strongly bound in Cloth, 
$6.00 net. 

The purpose of the writer in this work has been to furnish the student of His- 
tology, in one volume, with both the descriptive and the practical part of the 
science. The first two chapters are devoted to the consideration of the general 
methods of Histology ; subsequently, in each chapter, the structure of the tissue 
or organ is first systematically described, the student is then taken tutorially over 
the specimens illustrating it, and, finally, an appendix affords a short note of the 
methods of preparation. 

"We would most cordially recommend it to all students of histology." — Dublin Medical 
Journal. 

"It is pleasant to give unqualified praise to the colored illustrations ; . . . the standard is 
high, and many of them are not only extremely beautiful, but very clear and demonstra- 
tive. . . . The plan of the book is excellent." — Liverpool Medical Journal. 

ARCHIVES OF CLINICAL SKIAGRAPHY. By Sydney Rowland, 
B. A., Camb. A series of collotype illustrations, with descriptive text, 
illustrating the applications of the New Photography to Medicine and Sur- 
gery. Price, per Part, $1.00. Parts I. to V. now ready. 

The object of this publication is to put on record in permanent form some of 
the most striking applications of the new photography to the needs of Medicine 
and Surgery. 

The progress of this new art has been so rapid that, although Prof. Röntgen's 
discovery is only a thing of yesterday, it has already taken its place among the 
approved and accepted aids to diagnosis. 

WATER AND WATER SUPPLIES. By John C. Thresh, D. Sc, 
M. B., D. P. H., Lecturer on Public Health, King's College, London ; 
Editor of the "Journal of State Medicine," etc. i2mo, 438 pages, illus- 
trated. Handsomely bound in Cloth, with gold side and back stamps. 
Price, $2.25 net. 

This work will furnish any one interested in public health the information 
requisite for forming an opinion as to whether any supply or proposed supply 
is sufficiently wholesome and abundant, and whether the cost can be considered 
reasonable. 

The work does not pretend to be a treatise on Engineering, yet it contains 
sufficient detail to enable any one who has studied it to consider intelligently any 
scheme which may be submitted for supplying a community with water. 



CATALOGUE OF MEDICAL WORKS. 1 5 

DISEASES OF THE EYE. A Hand-Book of Ophthalmic Prac- 
tice. By G. E. de Schweinitz, M. D., Professor of Ophthalmology in 
the Jefferson Medical College, Philadelphia, etc. A handsome royal- 
octavo volume of 679 pages, with 256 fine illustrations, many of which are 
original, and 2 chromo-lithographic plates. Prices : Cloth, $4.00 net ; 
Sheep or Half-Morocco, $5.00 net. 

The object of this work is to present to the student, and to the practitioner 
who is beginning work in the fields of ophthalmology, a plain description of the 
optical defects and diseases of the eye. To this end special attention has been 
paid to the clinical side of' the question ; and the method of examination, the 
symptomatology leading to a diagnosis, and the treatment of the various ocular 
defects have been brought into prominence. 

SECOND EDITION, REVISED AND GREATLY ENLARGED. 

The entire book has been thoroughly revised. In addition to this general 
revision, special paragraphs on the following new matter have been introduced : 
Filamentous Keratitis, Blood-staining of the Cornea, Essential Phthisis Bulbi, 
Foreign Bodies in the Lens, Circinate Retinitis, Symmetrical Changes at the 
Macula Lutea in Infancy, Hyaline Bodies in the Papilla, Monocular Diplopia, 
Subconjunctival Injections of Germicides, Infiltration-Anaesthesia, and Steriliza- 
tion of Collyria. Brief mention of Ophthalmia Nodosa, Electric Ophthalmia, 
and Angioid Streaks in the Retina also finds place. An Appendix has been 
added, containing a full description of the method of determining the corneal 
astigmatism with the ophthalmometer of Javal and Schiötz, and the rotations 
of the eyes with the tropometer of Stevens. The chapter on Operations has 
been enlarged and rewritten. 

" A clearly written, comprehensive manual. . . . One which we can commend to students 
as a reliable text-book, written with an evident knowledge of the wants of those entering upon 
the study of this special branch of medical science."— British Medical Journal. 

" The work is characterized by a lucidity of expression which leaves the reader in no 
doubt as to the meaning of the language employed. . . . We know of no work in which 
these diseases are dealt with more satisfactorily, and indications for treatment more clearly 
given, and in harmony with the practice of the most advanced ophthalmologists." — Mari- 
time Medical News. 

" It is hardly too much to say that for the student and practitioner beginning the study of 
Ophthalmology, it is the best single volume at present published." — Medical News. 

" The latest and one of the best books on Ophthalmology. The book is thoroughly up to 
date, and is certainly a work which not only commends itself to the student, but is a ready 
reference for the busy practitioner." — International Medical Review. 

PROFESSIONAL OPINIONS. 

"A work that will meet the requirements not only of the specialist, but of the general 
practitioner in a rare degree. I am satisfied that unusual success awaits it." 

William Pepper, M. D. 
Provost and Professor of Theory and Practice of Medicine and Clinical Medicine 
in the University of Pennsylvania. 

" Contains in concise and reliable form the accepted views of Ophthalmic Science." 

William Thomson, M. D., 
Professor of Ophthalmology, Jefferson Medical College, Philadelphia, Pa. 



1 6 W. B. SAUNDERS' 



TEXT-BOOK UPON THE PATHOGENIC BACTERIA. Spe- 
cially written for Students of Medicine. By Joseph McFarland, 
M. D., Professor of Pathology and Bacteriology in the Medico-Chirurgical 
College of Philadelphia, etc. 359 pages, finely illustrated. Price, Cloth, 
#2.50 net. 

The book presents a concise account of the technical procedures necessary in 
the study of Bacteriology. It describes the life-history of pathogenic bacteria, and 
the pathological lesions following invasion. 

The work is intended to be a text-book for the medical student and for the 
practitioner who has had no recent laboratory training in this department of medi- 
cal science. The instructions given as to needed apparatus, cultures, stainings, 
microscopic examinations, etc., are ample for the student's needs, and will afford 
to the physician much information that will interest and profit him relative to a 
subject which modern science shows to go far in explaining the etiology of many 
diseased conditions. 

The illustrations have been gathered from standard sources, and comprise the 
best and most complete aggregation extant. 

" It is excellently adapted for the medical students and practitioners for whom it is avowedly 
written. . . . The descriptions given are accurate and readable, and the book should prove 
useful to those for whom it is written. — London Lancet, Aug. 29, 1896. 

" The author has succeded admirably in presenting the essential details of bacteriological 
technics, together with a judiciously chosen summary of our present knowledge of pathogenic 
bacteria. . . . The work, we think, should have a wide circulation among English-speaking 
students of medicine." — N. Y. Medical Journal, April 4, 1896. 

" The book will be found of considerable use by medical men who have not had a special 
bacteriological training, and who desire to understand this important branch of medical 
science." — Edinburgh Medical Journal, July, 1896. 

LABORATORY GUIDE FOR THE BACTERIOLOGIST. By 

Langdon Frothingham, M. D. V., Assistant in Bacteriology and Veteri- 
nary Science, Sheffield Scientific School, Yale University. Illustrated. 
Price, Cloth, 75 cents. 

The technical methods involved in bacteria-culture, methods of staining, and 
microscopical study are fully described and arranged as simply and concisely as 
possible. The book is especially intended for use in laboratory work 

" It is a convenient and useful little work, and will more than repay the outlay necessary 
for its purchase in the saving of time which would otherwise be consumed in looking up the 
various points of technique so clearly and concisely laid down in its pages." — American Med.- 
Surg. Bulletin. 

FEEDING IN EARLY INFANCY. By Arthur V. Meigs, M. D. 
Bound in limp cloth, flush edges. Price, 25 cents net. 

Synopsis : Analyses of Milk — Importance of the Subject of Feeding in Early 
Infancy — Proportion of Casein and Sugar in Human Milk — Time to Begin Arti- 
ficial Feeding of Infants — Amount of Food to be Administered at Each Feed- 
ing — Intervals between Feedings — Increase in Amount of Food at Different 
Periods of Infant Development — Unsuitableness of Condensed Milk as a Sub- 
stitute for Mother's Milk — Objections to Sterilization or "Pasteurization" of 
Milk — Advances made in the Method of Artificial Feeding of Infants. 

r 



CATALOGUE OF MEDICAL WORKS. \J 

ESSENTIALS OF ANATOMY AND MANUAL OF PRACTI- 
CAL DISSECTION, containing " Hints on Dissection." By Charles 
B. Nancrede, M. D., Professor of Surgery and Clinical Surgery in the 
University of Michigan, Ann Arbor ; Corresponding Member of the Royal 
Academy of Medicine, Rome, Italy ; late Surgeon Jefferson Medical Col- 
lege, etc. Fourth and revised edition. lost 8vo, over 500 pages, with 
handsome full-page lithographic plates in colors, and over 200 illustrations. 
Price : Extra Cloth or Oilcloth for the dissection-room, $2.00 net. 

Neither pains nor expense has been spared to make this work the most ex- 
haustive yet concise Student's Manual of Anatomy and Dissection ever pub- 
lished, either in America or in Europe. 

The colored plates are designed to aid the student in dissecting the muscles, 
arteries, veins, and nerves. The wood-cuts have all been specially drawn and 
engraved, and an Appendix added containing 60 illustrations representing the 
structure of the entire human skeleton, the whole being based on the eleventh 
edition of Gray's Anatomy. 



" The plates are of more than ordinary excellence, and are of especial value to students in 
their work in the dissecting-room."— Journal of American Medical Association. 

" Should be in the hands of every medical student." — Cleveland Medical Gazette. 

" A concise and judicious work." — Buffalo Medical and Surgical Journal. 

A MANUAL OF PRACTICE OF MEDICINE. By A. A. Stevens, 
A. M., M. D., Instructor of Physical Diagnosis in the University of Penn- 
sylvania, and Demonstrator of Pathology in the Woman's Medical College 
of Philadelphia. Specially intended for students preparing for graduation 
and hospital examinations, and includes the following sections : General 
Diseases, Diseases of the Digestive Organs, Diseases of the Respiratory 
System, Diseases of the Circulatory System, Diseases of the Nervous Sys- 
tem, Diseases of the Blood, Diseases of the Kidneys, and Diseases of the 
Skin. Each section is prefaced by a chapter on General Symptomatology. 
Post 8vo, 512 pages. Numerous illustrations and selected formulae. 
Price, #2.50. Bound in flexible leather. 

FOURTH EDITION, REVISED AND ENLARGED. 

Contributions to the science of medicine have poured in so rapidly during the 
last quarter of a century that it is well-nigh impossible for the student, with the 
limited time at his disposal, to master elaborate treatises or to cull from them 
that knowledge which is absolutely essential. From an extended experience in 
teaching, the author has been enabled, by classification, to group allied symp- 
toms, and by the judicious elimination of theories and redundant explanations 
to bring within a comparatively small compass a complete outline of the prac- 
tice of medicine. 



IV. B. SAUNDERS 



MANUAL OF MATERIA MEDICA AND THERAPEUTICS. 

By A. A. Stevens, A. M., M. D., Instructor of Physical Diagnosis in the 
University of Pennsylvania, and Demonstrator of Pathology in the Woman's 
Medical College of Philadelphia. 445 pages. Price, Cloth, #2.25. 

SECOND EDITION, REVISED. 

This wholly new volume, which is based on the last edition of the Pharma- 
copoeia, comprehends the following sections : Physiological Action of Drugs ; 
Drugs; Remedial Measures other than Drugs; Applied Therapeutics; Incom- 
patibility in Prescriptions ; Table of Doses ; Index of Drugs ; and Index of 
Diseases ; the treatment being elucidated by more than two hundred formulae. 

" The author is to be congratulated upon having presented the medical student with as 
accurate a manual of therapeutics as it is possible to prepare."— Therapeutic Gazette. 

" Far superior to most of its class ; in fact, it is very good. Moreover, the book is reliable 
and accurate." — New York Medical Journal. 

" The author has faithfully presented modern therapeutics in a comprehensive work, . . . 
and it will be found a reliable guide."— University Medical Magazine. 



NOTES ON THE NEWER REMEDIES: their Therapeutic Ap- 
plications and Modes of Administration. By David Cerna, M. D., 
Ph. D., Demonstrator of and Lecturer on Experimental Therapeutics in 
the University of Pennsylvania. Post-octavo, 253 pages. Price, #1.25. 

SECOND EDITION, RE-WRITTEN AND GREATLY ENLARGED. 

The work takes up in alphabetical order all the newer remedies, giving their 
physical properties, solubility, therapeutic applications, administration, and 
chemical formula. 

It thus forms a very valuable addition to the various works on therapeutics 
now in existence. 

Chemists are so multiplying compounds, that,, if each compound is to be thor- 
oughly studied, investigations must be carried far enough to determine the prac- 
tical importance of the new agents. 

"Especially valuable because of its completeness, its accuracy, its systematic consider- 
ation of the properties and therapy of many remedies of which doctors generally know but 
little, expressed in a brief yet terse manner." — Chicago Clinical Review. 



TEMPERATURE CHART. Prepared by D. T. Laine, M. D. Size 
8x 1^)4 inches. Price, per pad of 25 charts, 50 cents. 

A conveniently arranged chart for recording Temperature, with columns for 
daily amounts of Urinary and Fecal Excretions, Food, Remarks, etc. On the 
back of each chart is given in full the method of Brand in the treatment of 
Typhoid Fever. 



CATALOGUE OF MEDICAL WORKS. 1 9 

SAUNDERS' POCKET MEDICAL LEXICON; or, Dictionary of 

Terms and Words used in Medicine and Surgery. By John M. 
Keating, M. D., editor of " Cyclopaedia of Diseases of Children," etc. ; 
author of the " New Pronouncing Dictionary of Medicine;" and Henry 
Hamilton, author of " A New Translation of Virgil's ^Eneid into Eng- 
lish Verse;" co-author of a " New Pronouncing Dictionary of Medicine." 
A new and revised edition. 32mo, 282 pages. Prices: Cloth, 75 cents; 
Leather Tucks, #1.00. 

This new and comprehensive work of reference is the outcome of a demand 
for a more modern handbook of its class than those at present on the market, 
which, dating as they do from 1 85 5 to 1 884, are of but trifling use to the student 
by their not containing the hundreds of new words now used in current litera- 
ture, especially those relating to Electricity and Bacteriology. 

" Remarkably accurate in terminology, accentuation, and definition."— Journal of Amer- 
ican Medical Association. 

" Brief, yet complete .... it contains the very latest nomenclature in even the newest 
departments of medicine." — New York Medical Record. 



SAUNDERS* POCKET MEDICAL FORMULARY. By William 
M. Powell, M. D., Attending Physician to the Mercer House for Invalid 
Women at Atlantic City. Containing 1750 Formulae, selected from several 
hundred of the best-known authorities. Forming a handsome and con- 
venient pocket companion of nearly 300 printed pages, with blank leaves 
for Additions; with an Appendix containing Posological Table, Formulae 
and Doses for Hypodermatic Medication, Poisons and their Antidotes, 
Diameters of the Pemale Pelvis and Foetal Head, Obstetrical Table, Diet 
List for Various Diseases, Materials and Drugs used in Antiseptic Surgery, 
Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables 
of Incompatibles, Eruptive Fevers, Weights and Measures, etc. Third 
edition, revised and greatly enlarged. Handsomely bound in morocco, 
with side index, wallet, and flap. Price, $1.75 net. 

A concise, clear, and correct record of the many hundreds of famous formulae 
which are found scattered through the works of the most eminent physicians 
and surgeons of the world. The work is helpful to the student and practitioner 
alike, as through it they become acquainted with numerous formulae which are 
not found in text-books, but have been collected from among the rising genera- 
tion of the profession, college professors, and hospital physicians and surgeons. 

" This little book, that can be conveniently carried in the pocket, contains an immense 
amount of material. It is very useful, and as the name of the author of each prescription is 
given is unusually reliable."— Neiu York Medical Record. 

" Designed to be of immense help to the general practitioner in the exercise of his daily 
calling." — Boston Medical and Surgical Journal. 



20 W. B. SAUNDERS' 



DISEASES OF WOMEN. By Henry J. Garrigues, A. M., M. D., 
Professor of Gynecology and Obstetrics in the New York School of Clinical 
Medicine ; Gynecologist to St. Mark's Hospital and to the German Dis- 
pensary, New York City. In one handsome octavo volume of 728 pages, 
illustrated by 335 engravings and colored plates. Prices : Cloth, $4.00 net ; 
Sheep or Half Morocco, $5.00 net. 

A practical work on gynecology for the use of students and practitioners, 
written in a terse and concise manner. The importance of a thorough know- 
ledge of the anatomy of the female pelvic organs has been fully recognized by 
the author, and considerable space has been devoted to the subject. The chap- 
ters on Operations and on Treatment are thoroughly modern, and are based 
upon the large hospital and private practice of the author. The text is eluci- 
dated by a large number of illustrations and colored plates, many of them being 
original, and forming a complete atlas for studying embryology and the anatomy 
of the female genitalia, besides exemplifying, whenever needed, morbid condi- 
tions, instruments, apparatus, and operations. 

Second Edition, Thoroughly Revised. 

The first edition of this work met with a most appreciative reception by the 
medical press and profession both in this country and abroad, and was adopted 
as a text-book or recommended as a book of reference by nearly one hundred 
colleges in the United States and Canada. The author has availed himself of 
the opportunity afforded by this revision to embody the latest approved advances 
in the treatment employed in this important branch of Medicine. He has also 
more extensively expressed his own opinion on the comparative value of the 
different methods of treatment employed. 

" One of the best text-books for students and practitioners which has been published in 
the English language ; it is condensed, clear, and comprehensive. The profound learning 
and great clinical experience of the distinguished author find expression in this book in a 
most attractive and instructive form. Young practitioners, to whom experienced consultants 
may not be available, will find in this book invaluable counsel and help." 

Thad. A. Reamy, M. D., LL.D., 
Professor of Clinical Gynecology , Medical College of Ohio ; Gynecologist to the Good 
Samaritan and Cincinnati Hospitals. 



A SYLLABUS OF GYNECOLOGY, arranged in conformity with 
"An American Text-Book of Gynecology." By J. W. Long, M. D., 
Professor of Diseases of Women and Children, Medical College of Vir- 
ginia, etc. Price, Cloth (interleaved), $1.00 net. 

Based upon the teaching and methods laid down in the larger work, this will 
not only be useful as a supplementary volume, but to those who do not already 
possess the text-book it will also have an independent value as an aid to the 
practitioner in gynecological work, and to the student as a guide in the lecture- 
room, as the subject is presented in a manner at once systematic, clear, succinct, 
?nd practical. 



CATALOGUE OF MEDICAL WORKS. 21 

A MANUAL OF PHYSIOLOGY, with Practical Exercises. For 

Students and Practitioners. By G. N. Stewart, M. A., M. D., D. Sc, 

lately Examiner in Physiology, University of Aberdeen, and of the New 

Museums, Cambridge University ; Professor of Physiology in the Western 

Reserve University, Cleveland, Ohio. Handsome octavo volume of 800 

pages, with 278 illustrations in the text, and 5 colored plates. Price, 

Cloth, $3.50 net. 

" It will make its way by sheer force of merit, and amply deserves to do so. It is one of 
the very best English text-books on the szibject." — London Lancet. 

" Of the many text-books of physiology published, we do not know of one that so nearly 
comes up to the ideal as does Professor Stewart's volume." — British Medical Journal. 

ESSENTIALS OF PHYSICAL DIAGNOSIS OF THE THORAX. 

By Arthur M. Corwin, A. M., M. D., Demonstrator of Physical Diagno- 
sis in the Rush Medical College, Chicago; Attending Physician to the 
Central Free Dispensary, Department of Rhinology, Laryngology, and 
Diseases of the Chest. 200 pages. Illustrated. Cloth, flexible covers. 
Price, $1.25 net. 

SYLLABUS OF OBSTETRICAL LECTURES in the Medical 
Department, University of Pennsylvania. By Richard C. Norris, 
A. M., M. D., Lecturer on Clinical and Operative Obstetrics, University 
of Pennsylvania. Third edition, thoroughly revised and enlarged. Crown 
8vo. Price, Cloth, interleaved for notes, $2.00 net. 

" This work is so far superior to others on the same subject that we take pleasure in call- 
ing attention briefly to its excellent features. It covers the subject thoroughly, and will 
prove invaluable both to the student and the practitioner. The author has introduced a 
number of valuable hints which would only occur to one who was himself an experienced 
teacher of obstetrics. The subject-matter is clear, forcible, and modern. We are especially 
pleased with the portion devoted to the practical duties of the accoucheur, care of the child, 
etc. The paragraphs on antiseptics are admirable; there is no doubtful tone in the direc- 
tions given. No details are regarded as unimportant; no minor matters omitted. We ven- 
ture to say that even the old practitioner will find useful hints in this direction which he can- 
not afford to despise." — New York Medical Record. 

A SYLLABUS OF LECTURES ON THE PRACTICE OF SUR- 
GERY, arranged in conformity with " An American Text-Book 
of Surgery." By N. Senn, M. D., Ph. D., Professor of Surgery in Rush 
Medical College, Chicago, and in the Chicago Polyclinic. Price, $2.00. 

This, the latest work of its eminent author, himself one of the contributors 
to "An American Text-Book of Surgery," will prove of exceptional value to 
the advanced student who has adopted that work as his text-book. It is not 
only the syllabus of an unrivalled course of surgical practice, but it is also an 
epitome of or supplement to the larger work. 

" The author has evidently spared no pains in making his Syllabus thoroughly comprehen- 
sive, and har. added new matter and alluded to the most recent authors and operations. Full 
references are also given to all requisite details of surgical anatomy and pathology."— British 
Medical Journal, London. 



22 W. B. SAUNDERS' 



AN OPERATION BLANK, with Lists of Instruments, etc. re- 
quired in Various Operations. Prepared by W. W. Keen, M. D., 
LL.D., Professor of Principles of Surgery in the Jefferson Medical Col- 
lege, Philadelphia. Price per Pad, containing Blanks for fifty operations, 
50 cents net. 

SECOND EDITION, REVISED FORM. 

A convenient blank, suitable for all operations, giving complete instructions 
regarding necessary preparation of patient, etc., with a full list of dressings and 
medicines to be employed. 

On the back of each blank is a list of instruments used — viz. general instru- 
ments, etc., required for all operations ; and special instruments for surgery of 
the brain and spine, mouth and throat, abdomen, rectum, male and female 
genito-urinary organs, the bones, etc. 

The whole forming a neat pad, arranged for hanging on the wall of a sur- 
geon's office or in the hospital operating-room. 

" Will serve a useful purpose for the surgeon in reminding him of the details of prepa- 
ration for the patient and the room as well as for the instruments, dressings, and antiseptics 
needed." — New York Medical Record 

"Covers about all that can be needed in any operation." — American Lancet, 

" The plan is a capital one."— Boston Medical and Surgical Journal. 

LABORATORY EXERCISES IN BOTANY. By Edson S. Bastin, 
M. A., Professor of Materia Medica and Botany in the Philadelphia Col- 
lege of Pharmacy. Octavo volume of 536 pages, 87 full-page plates. Price, 
Cloth, #2.50. 

This work is intended for the beginner and the advanced student, and it fully 
covers the structure of flowering plants, roots, ordinary stems, rhizomes, tubers, 
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and microscopical structure of plants, and to those used in medicine. Illustra- 
tions have freely been used to elucidate the text, and a complete index to facil- 
itate reference has been added. 

" There is no work like it in the pharmaceutical or botanical literature of this country, and 
we predict for it a wide circulation." — American Journal 0/ Pharmacy. 

DIET IN SICKNESS AND IN HEALTH. By Mrs. Ernest Hart, 
formerly Student of the Faculty of Medicine of Paris and of the London 
School of Medicine for Women; with an Introduction by Sir Henry 
Thompson, F. R. C. S., M. D., London. 220 pages; illustrated. Price, 
Cloth, #1.50. 

Useful to those who have to nurse, feed, and prescribe for the sick. In 
each case the accepted causation of the disease and the reasons for the special 
diet prescribed are briefly described. Medical men will find the dietaries and 
recipes practically useful, and likely to save them trouble in directing the dietetic 
treatment of patients. 



CATALOGUE OF MEDICAL WORKS. 2$ 



HOW TO EXAMINE FOR LIFE INSURANCE. By John M. 
Keating, M. D., Fellow of the College of Physicians and Surgeons of 
Philadelphia; Vice-President of the American Pediatric Society; Ex- 
President of the Association of Life Insurance Medical Directors. Royal 
8vo, 211 pages, with two large half-tone illustrations, and a plate prepared 
by Dr. McClellan from special dissections ; also, numerous cuts to elucidate 
the text. Second edition. Price, Cloth, $2.00 net. 

" This is by far the most useful book which has yet appeared on insurance examination, a 
subject of growing interest and importance. Not the least valuable portion of the volume is 
Part II., which consists of instructions issued to their examining physicians by twenty-four 
representative companies of this country. As the proofs of these instructions were corrected 



by the directors of the companies, they form the latest instructions obtainable. If for these 
alone, the book should be at the right hand of every ]_ ' 
of medical science." — The Medical News, Philadelphia. 



lone, the book should be at the right hand of every physician interested in this special branch 



NURSING: ITS PRINCIPLES AND PRACTICE. By Isabel 
Adams Hampton, Graduate of the New York Training School for 
Nurses attached to Bellevue Hospital; Superintendent of Nurses and 
Principal of the Training School for Nurses, Johns Hopkins Hospital, 
Baltimore, Md. ; late Superintendent of Nurses, Illinois Training School 
for Nurses, Chicago, 111. In one very handsome i2mo volume of 484 
pages, profusely illustrated. Price, Cloth, $2.00 net. 

This original work on the important subject of nursing is at once comprehensive 
and systematic. It is written in a clear, accurate, and readable style, suitable 
alike to the student and the lay reader. Such a work has long been a desidera- 
tum with those entrusted with the management of hospitals and the instruction of 
nurses in training-schools. It is also of especial value to the graduated nurse 
who desires to acquire a practical working knowledge of the care of the sick 
and the hygiene of the sick-room. 

OBSTETRIC ACCIDENTS, EMERGENCIES, AND OPERA- 
TIONS. By L. Ch. Boisliniere, M. D., late Emeritus Professor of 
Obstetrics in the St. Louis Medical College. 381 pages, handsomely illus- 
trated. Price, #2.00 net. 

" For the use of the practitioner who, when away from home, has not the 
opportunity of consulting a library or of calling a friend in consultation. He 
then, being thrown upon his own resources, will find this book of benefit in 
guiding and assisting him in emergencies." 

INFANT'S WEIGHT CHART. Designed by J. P. Crozer Griffith, 
M. D., Clinical Professor of Diseases of Children in the University of Penn- 
sylvania. 25 charts in each pad. Price per pad, 50 cents net. 

A convenient blank for keeping a record of the child's weight during the first 
two years of life. Printed on each chart is a curve representing the average weight 
of a healthy infant, so that any deviation from the normal can readily be detected. 



24 W. B. SAUNDERS' 



THE CARE OF THE BABY. By J. P. Crozer Griffith, M. D., 
Clinical Professor of Diseases of Children, University of Pennsylvania; 
Physician to the Children's Hospital, Philadelphia, etc. 392 pages, with 
67 illustrations in the text, and 5 plates. i2mo. Price, $1.50. 

A reliable guide not only for mothers, but also for medical students and 
practitioners whose opportunities for observing children have been limited. 

" The whole book is characterized by rare good sense, and is evidently written by a mas- 
ter hand. _ It can be read with benefit not only by mothers, but by medical students and by 
any practitioners who have not had large opportunities for observing children." — American 
Journal of Obstetrics. 

THE NURSE'S DICTIONARY of Medical Terms and Nursing 
Treatment, containing Definitions of the Principal Medical and Nursing 
Terms, Abbreviations, and Physiological Names, and Descriptions of the 
Instruments, Drugs, Diseases, Accidents, Treatments, Operations, Foods, 
Appliances, etc. encountered in the ward or in the sick-room. Compiled 
for the use of nurses. By Honnor Morten, author of " How to Become 
a Nurse," "Sketches of Hospital Life," etc. i6mo, 140 pages. Price, 
Cloth, #1.00. 

This little volume is intended for use merely as a small reference-book which 
can be consulted at the bedside or in the ward. It gives sufficient explanation 
to the nurse to enable her to comprehend a case until she has leisure to look up 
larger and fuller works on the subject. 

DIET LISTS AND SICK-ROOM DIETARY. By Jerome B. Thomas, 
M. D., Visiting Physician to the Home for Friendless Women and Children 
and to the Newsboys' Home ; Assistant Visiting Physician to the Kings 
County Hospital ; Assistant Bacteriologist, Brooklyn Health Department. 
Price, Cloth, $1.50 (Send for specimen List.) 

One hundred and sixty detachable (perforated) diet lists for Albuminuria, 
Ansemia and Debility, Constipation, Diabetes, Diarrhoea, Dyspepsia, Fevers, 
Gout or Uric-Acid Diathesis, Obesity, and Tuberculosis. Also forty detachable 
sheets of Sick-Room Dietary, containing full instructions for preparation of 
easily-digested foods necessary for invalids. Each list is numbered only, the 
disease for which it is to be used in no case being mentioned, an index key 
being reserved for the physician's private use. 

DIETS FOR INFANTS AND CHILDREN IN HEALTH AND 
IN DISEASE. By Louis Starr, M. D., Editor of " An American 
Text-Book of the Diseases of Children." 230 blanks (pocket-book size), 
perforated and neatly bound in flexible morocco. Price, #1.25 net. 

The first series of blanks are prepared for the first seven months of infant 
life; each blank indicates the ingredients, but not the quantities, of the food, 
the latter directions being left for the physician. After the seventh month, 
modifications being less necessary, the diet lists are printed in full. Formula 
foi trie preparation of diluents and foods are appended. 




saunders' 
New Series 
of Manuals 



for Students 
and 
Practitioners, 



THAT there exists a need for thoroughly reliable hand-books on the leading 
branches of Medicine and Surgery is a fact amply demonstrated by the 
favor with which the SAUNDERS NEW SERIES OF MANUALS have been 
received by medical students and practitioners and by the Medical Press. 
These manuals are not merely condensations from present literature, but 
are ably written by well-known authors and practitioners, most of them being 
teachers in representative American colleges'. Each volume is concisely and 
authoritatively written and exhaustive in detail, without being encumbered 
with the introduction of "cases," which so largely expand the ordinary text- 
book. These manuals will therefore form an admirable collection of advanced 
lectures, useful alike to the medical student and the practitioner: to the latter, 
too busy to search through page after page of elaborate treatises for what he 
wants to know, they will prove of inestimable value ; to the former they will 
afford safe guides to the essential points of study. 

The SAUNDERS NEW SERIES OF MANUALS are conceded to be 
superior to any similar books now on the market. No other manuals afford so 
much information in such a concise and available form. A liberal expenditure 
has enabled the publisher to render the mechanical portion of the work worthy 
of the high literary standard attained by these books. 

Any of these Manuals will be mailed on receipt of price (see next page 
for List). 

W. B. SAUNDERS, Publisher, 

925 Walnut Street, Pniladelphia* 



SAUNDERS' NEW SERIES OF MANUALS. 



VOLUMES PUBLISHED. 



PHYSIOLOGY. By Joseph Howard Raymond, A. M., M. D., Professor 

of Physiology and Hygiene and Lecturer on Gynecology in the Long 
Island College Hospital, etc. Price, $1.25 net. 

SURGERY, General and Operative. By John Chalmers DaCosta, 
M. D,, Demonstrator of Surgery, Jefferson Medical College, Philadelphia, 
etc. Double number. New and Enlarged Edition in Preparation. 

DOSE-BOOK AND MANUAL OF PRESCRIPTION-WRITING. 

By E. Q. Thornton, M. D., Demonstrator of Therapeutics, Jefferson 
Medical College, Philadelphia. Price, #1.25 net. 

MEDICAL JURISPRUDENCE. By Henry C. Chapman, M. D., Pro- 
fessor of Institutes of Medicine and Medical Jurisprudence in the Jeffer- 
son Medical College of Philadelphia, etc Price, #1.50 net. 

SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's 
Hospital and to the German Poliklinik ; Instructor in Surgery, New York 
Post-Graduate Medical School, etc. Price, #1.25 net. 

MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct 
Professor of Anatomy and Demonstrator of Anatomy, Medical Department 
of the New York University, etc. (Double number.) Price, $2.50 net. 

SYPHILIS AND THE VENEREAL DISEASES. By James 
Nevins Hyde, M. D., Professor of Skin and Venereal Diseases, and 
Frank H. Montgomery, M. D., Lecturer on Dermatology and Genito- 
urinary Diseases, in Rush Medical College, Chicago. (Double number.) 
Price, $2.50 net. 

PRACTICE OF MEDICINE. By George Roe Lockwood, M. D., 
Professor of Practice in the Woman's Medical College of the New 
York Infirmary, etc. (Double number.) Price, $2.50 net. 

OBSTETRICS. By W. A. Newman Dorland, M. D., Asst. Demonstrator 
of Obstetrics, University of Pennsylvania ; Chief of Gynecological Dispen- 
sary, Pennsylvania Hospital. (Double number.) Price, $2.50 net. 

DISEASES OF WOMEN. By J. Bland Sutton, F. R. C. S., Assistant 
Surgeon to the Middlesex Hospital, and Surgeon to the Chelsea Hospital 
for Women, London; and Arthur E. Giles, M. D., .B. Sc. Lond., 
F. R. C. S. Edin., Assistant Surgeon to the Chelsea Hospital for Women, 
London. 436 pages, handsomely illustrated. (Double number.) Price, 
#2.50 net. 

VOLUMES IN PREPARATION. 
NERVOUS DISEASES. By Charles W. Burr, M. D., Clinical Pro- 
fessor of Nervous Diseases, Medico-Chirurgical College, Philadelphia, etc. 

NOSE AND THROAT. By D. Braden KYLJJ, M. D., Chief Laryngolo- 
gist to St. Agnes' Hospital, Philadelphia; Instructor in Clinical Microscopy 
and Assistant Demonstrator of Pathology in Jefferson Medical College. 

%* There will be published in the same series, at short intervals, carefully 
prepared works on various subjects, by prominent specialists. 



SAUNDERS' QUESTION COMPENDS. 

Arranged in Question and Answer Form, 



THE LATEST, MOST COMPLETE, and BEST ILLUSTRATED 
SERIES OF COMPENDS EVER ISSUED. 



Now the Standard Authorities in Medical Literature 



Students and Practitioners in every City of the United 
States and Canada. 



THE REASON WHY. 

They are the advance guard of " Student's Helps " — that DO help; they are 
the leaders in their special line, well and authoritatively written by able men, 
who, as teachers in the large colleges, know exactly what is wanted by a student 
preparing for his examinations. The judgment exercised in the selection of 
authors is fully demonstrated by their professional elevation. Chosen from the 
ranks of Demonstrators, Quiz-masters, and Assistants, most of them have be- 
come Professors and Lecturers in their respective colleges. 

Each book is of convenient size (5x7 inches), containing on an average 250 
pages, profusely illustrated, and elegantly printed in clear, readable type, on 
fine paper. 

The entire series, numbering twenty- four subjects, has been kept thoroughly 
revised and enlarged when necessary, many of them being in their fourth and 
fifth editions. 

TO SUM UP. 

Although there are numerous other Quizzes, Manuals, Aids, etc. in the mar- 
ket, none of them approach the " Blue Series of Question Compends;" and 
the claim is made for the following points of excellence : 

1. Professional distinction and reputation of authors. 

2. Conciseness, clearness, and soundness of treatment. 

3. Size of type and quality of paper and binding. 

*** Any of these Compends will bs mailed on receipt of price (see over 
for List). 



SAUNDERS' QUEST10N-C0MPEND SERIES. 

Price, Cloth, $1.00 per copy, except when otherwise noted. 



1. ESSENTIALS OF PHYSIOLOGY. 4th edition. Illustrated. Re- 

vised and enlarged by H. A. Hare, M. D (Price, $1.00 net.) 

2. ESSENTIALS OF SURGERY. 6th edition, with an Appendix on 

Antiseptic Surgery. 90 illustrations. By Edward Martin, M. D. 

3. ESSENTIALS OF ANATOMY. 5th edition, with an Appendix. 180 

illustrations. By Charles B. Nancrede, M. D. 

4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND 

INORGANIC. 4th edition, revised, with an Appendix. By Law- 
rence Wolff, M. D. 

5. ESSENTIALS OF OBSTETRICS. 4th edition, revised and en- 

larged. 75 illustrations. By W. Easterly Ashton, M. D. 

6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. 

7th thousand. 46 illustrations. By C. E. Armand Semple, M. D. 

7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, 

AND PRESCRIPTION-WRITING. 4Ü1 edition. By Henry 
Morris, M. D. 

8. 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry 

Morris, M. D. An Appendix on Urine Examination. Illustrated. 
By Lawrence Wolff, M. D. 3d edition, enlarged by some 300 Es- 
sential Formulae, selected from eminent authorities, by Wm. M. Powell, 
M. D. (Double number, price $2.00.) 

10. ESSENTIALS OF GYNAECOLOGY. 4th edition, revised. With 

62 illustrations. By Edwin B. Cragin, M. D. 

11. ESSENTIALS OF DISEASES OF THE SKIN. 3d edition, re- 

vised and enlarged. 71 letter-press cuts and 15 half-tone illustrations. 
By Henry W. Stelwagon, M. D. (Price, #1.00 net.) 

12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND 

VENEREAL DISEASES. 2d edition, revised and enlarged. 78 
illustrations. By Edward Martin, M. D. 

13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND 

HYGIENE. 130 illustrations. By C. E. Armand Semple, M. D. 

14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND 

THROAT. 124 illustrations. 2d edition, revised. By Edward 
Jackson, M. D., and E. Baldwin Gleason, M. D. 

15. ESSENTIALS OF DISEASES OF CHILDREN. Second edi 

tion. By William H. Powell, M. D. 

16. ESSENTIALS OF EXAMINATION OF URINE. Colored 

" Vogel Scale," and numerous illustrations. By Lawrence Wolff, 
M. D. (Price, 75 cents.) 

17. ESSENTIALS OF DIAGNOSIS. By S. Solis-Cohen, M. D., and 

A. A. Eshner, M. D. 55 illustrations, some in colors. (Price, $1 .50 net.) 

18. ESSENTIALS OF PRACTICE OF PHARMACY. By L. E. 

Sayre. 2d edition, revised. 

20. ESSENTIALS OF BACTERIOLOGY. 3d edition. 82 illustra- 
tions. By M. V. Ball, M. D. 

ax. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. 
48 illustrations. 3d edition, revised. By John C. Shaw, M. D. 

22. ESSENTIALS OF MEDICAL PHYSICS. 155 illustrations. 2d 

edition, revised. By Fred J. Brockway, M. D. (Price, $1.00 net.) 

23. ESSENTIALS OF MEDICAL ELECTRICITY. 65 illustrations. 

By David D. Stewart, M. D., and Edward S. Lawrance, M. D. 

24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gle\- 

son, M. D. 114 illustrations. Second edition, revised and enlarged. 



RECENT PUBLICATIONS 



PENROSE'S DISEASES OF WOMEN 

A Text-Book of Diseases of Women. By Charles B. Penrose, M.D., Ph.D., 
Professor of Gynecology in the University of Pennsylvania ; Surgeon to the Gynecean 
Hospital, Philadelphia. Octavo volume of 529 pages, handsomely illustrated. Cloth, 
I3.50 net. 

"I shall value very highly the copy of Penrose's "Diseases of Women " received. 
I have already recommended it to my class as the best book." — Howard A. Kelly, 
Professor of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Md. 

SENN'S GENITOURINARY TUBERCULOSIS 

Tuberculosis of the Genito=Urinary Organs, Male and Female. By Nicholas 
Senn, M.D., Ph.D., LL.D., Professor of the Practice of Surgery and of Clinical 
Surgery, Rush Medical College, Chicago. Handsome octavo volume of 320 pages, 
illustrated. Cloth, $3.00 net. 

SUTTON AND GILES» DISEASES OF WOMEN 

Diseases of Women. By J. Bland Sutton, F.R.C.S., Assistant Surgeon to Middle- 
sex Hospital, and Surgeon to Chelsea Hospital, London ; and Arthur E. Giles, 
M.D., B.Sc. Lond., F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, London. 
436 pages, handsomely illustrated. Cloth, $2.50 net. 

BUTLER'S MATERIA MEDICA, THERAPEUTICS, AND PHAR= 
MACOLOGY 

A Text=Book of Materia Medica, Therapeutics, and Pharmacology. By George 
F. Butler, Ph.G., M.D., Professor of Materia Medica and of Clinical Medicine in 
the College of Physicians and Surgeons, Chicago; Professor of Materia Medica and 
Therapeutics, Northwestern University, Woman's Medical School, etc. Octavo, 858 
pages, illustrated. Cloth, $4.00 net ; Sheep, $5.00 net. 

SAUNDBY'S RENAL AND URINARY DISEASES 

Lectures on Renal and Urinary Diseases. By Robert Saundby, M.D. Edin., 
Fellow of the Royal College of Physicians, London, and of the Royal Medico-Chirur- 
gical Society ; Physician to the General Hospital; Consulting Physician to the Eye 
Hospital and to the Hospital for Diseases of Women ; Professor of Medicine in Mason 
College, Birmingham, etc. Octavo volume of 434 pages, with numerous illustrations 
and 4 colored plates. Cloth, $2.50 net. 

PYE'S BANDAGING 

Elementary Bandaging and Surgical Dressing, with Directions Concerning 
the Immediate Treatment of Cases of Emergency. For the Use of Dressers 
and Nurses. By Walter Pye, F.R.C.S., Late Surgeon to St. Mary's Hospital, 
London. Small i2mo, with over 80 illustrations. Cloth, flexible covers. Price, 75 
cents net. 

MALLORY AND WRIGHT'S PATHOLOGICAL TECHNIQUE 

Pathological Technique. By Frank B. Mallory, A.M., M.D., Assistant Professor 
of Pathology, Harvard University Medical School ; and James H. Wright, A.M., 
M.D.. Instructor in Pathology, Harvard University Medical School. Octavo volume 
of 396 pages, handsomely illustrated. Cloth, $2.50 net. 

" I have been looking forward to the publication of this book, and I am glad to say 
that I find it to be a most useful laboratory and post-mortem guide, full of practical infor- 
mation, and well up to date."— William H. Welch, Professor of Pathology, Johns 
Hopkins University, Baltimore, Md. 

ANDERS' PRACTICE OF MEDICINE 

A Text-Book of the Practice of Medicine. By James M. Anders, M.D., Ph.D., 
LL.D., Professor of the Practice of Medicine and of Clinical Medicine, Medico- 
Chirurgical College, Philadelphia. In one handsome octavo volume of 1287 pages, 
fully illustrated. Cloth, $5.50 net ; Sheep or Half Morocco, $6.50 net. 

29 



JUST ISSUED. SOLD BY SUBSCRIPTION. 

ANOMALIES 

AND 

CURIOSITIES OF MEDICINE. 

BY 

GEORGE M. GOULD, M. D., and WALTER L. PYLE, M. D. 

Several years of exhaustive research have been spent by the authors in the 
great medical libraries of the United States and Europe in collecting the material 
for this work, fledical literature of all ages and all languages has 
been carefully searched, as a glance at the Bibliographic Index will show. Tha 
facts, which will be of extreme value to the author and lecturer, have 
been arranged and annotated, and full reference footnotes given, indicating 
whence they have been obtained. 

In view of the persistent and dominant interest in the anomalous and curious, 
a thorough and systematic collection of this kind (the first of which the 
authors have knowledge) must have its own peculiar sphere of usefulness. 

As a complete and authoritative Book of Reference it will be of value 
not only to members of the medical profession, but to all persons interested in 
general scientific, sociologic, and medico-legal topics ; in fact, the general inter- 
est of the subject and the dearth of any complete work upon it make this 
volume one of the most important literary innovations of the day. 

An especially valuable feature of the book consists of the Indexinge 
Besides a complete and comprehensive General Index, containing numerous 
cross-references to the subjects discussed, and the names of the authors of the 
more important reports, there is a convenient Bibliographic Index and a 
Table of Contents. 

The plan has been adopted of printing the topical headings in bold = 
face type, the reader being thereby enabled to tell at a glance the subject- 
matter of any particular paragraph or page. 

Illustrations have been freely employed throughout the work, there being 
165 relief cuts and 130 half-tones in the text, and 12 colored and half-tone full- 
page plates — a total of over 320 separate figures. 

The careful rendering of the text and references, the wealth of illustrations, 
the mechanical skill represented in the typography, the printing, and the bind- 
ing, combine to make this book one of the most attractive medical publications 
ever issued. 

Handsome Imperial Octavo Volume of 968 Pages. 
PRICES: Cloth, $6.00 net; Half Morocco, $7.00 net. 
30 



JUST ISSUED 



AN AMERICAN TEXT=BOOK OF GENITOURINARY AND SKIN 
DISEASES 

Edited by L. Bolton Bangs, M.D., Late Professor of Genito-Urinary and Venereal 
Diseases, New York Post-Graduate Medical School and Hospital ; and William 
A. Hardaway, M.D., Professor of Diseases of the Skin, Missouri Medical College. 
Octavo volume of over 1200 pages, with 300 illustrations in the text, and 20 full-page 
colored plates. Prices : Cloth, $7.00 net ; Sheep or Half Morocco, $8.00 net. 

MOORE'S ORTHOPEDIC SURGERY 

A Manual of Orthopedic Surgery. By James E. Moore, M.D., Professor of Ortho- 
pedics and Adjunct Professor of Clinical Surgery, University of Minnesota, College 
of Medicine and Surgery. 8vo, 356 pages, handsomely illustrated. Cloth, $2. 50 net. 

MACDONALD'S SURGICAL DIAGNOSIS AND TREATMENT 

Surgical Diagnosis and Treatment. By J. W. Macdonald, M.D. Edin., L.R.C.S. 
Edin., Professor of the Practice of Surgery and of Clinical Surgery in Hamline Uni- 
versity; Visiting Surgeon to St. Barnabas' Hospital, Minneapolis, etc. Octavo 
volume of 800 pages, handsomely illustrated. Cloth, $5.00 net; Half Morocco, $6.oo net. 

CHAPIN ON INSANITY 

A Compendium of Insanity. By John B. Chapin, M.D., LL.D., Physician-in-Chief, 
Pennsylvania Hospital for the Insane; late Physician-Superintendent of the Willard 
State Hospital, New York, etc. 121110., 234 pages, illustrated. Cloth, $1.25 net. 

KEEN ON THE SURGERY OF TYPHOID FEVER 

The Surgical Complications and Sequels of Typhoid Fever. By Wm. W. Keen, 
M.D., LL.D., Professor of the Principles of Surgery and of Clinical Surgery, Jeffer- 
son Medical College, Philada. Octavo volume of 400 pages. Cloth, $3.00 net. 

VAN VALZAH AND NISBET'S DISEASES OF THE STOMACH 

Diseases of the Stomach. By William W. van Valzah, M.D., Professor of General 
Medicine and Diseases of the Digestive System and the Blood, New York Polyclinic ; 
and J. Douglas Nisbet, M.D., Adjunct Professor of General Medicine and Diseases 
of the Digestive System and the Blood,. New York Polyclinic. Octavo volume of 674 
pages, illustrated. Cloth, $3.50 net. 

IN PREPARATION 

AN AMERICAN TEXT=BOOK OF DISEASES OF THE EYE, EAR, 
NOSE, AND THROAT 

Edited by G. E. de Schweinitz, M.D., Professor of Ophthalmology in the Jefferson 
Medical College ; and B.Alexander Randall, M.D., Professor of Diseases of the 
Ear in the University of Pennsylvania and in the Philadelphia Polyclinic. 

CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES 

Nervous and Mental Diseases. By Archibald Church, M.D., Professor of Mental 
Diseases and Medical Jurisprudence, Northwestern University Medical School, 
Chicago; and Frederick Peterson, M.D. , Clinical Professor of Mental Diseases, 
Woman's Medical Colfege, New York, etc. 

KYLE ON THE NOSE AND THROAT 

Diseases of the Nose and Throat. By D. Braden Kyle, M.D., Clinical Professor 
of Laryngology and Rhinology, Jefferson Medical College, Philadelphia ; Consulting 
Laryngologist, Rhinologist, and Otologist, St. Agnes' Hospital, etc. 

STENGEL'S PATHOLOGY 

A Manual of Pathology. By Alfred Stengel, M.D., Physician to the Philadel- 
phia Hospital; Professor of Clinical Medicine in the Woman's Medical College; 
Physician to the Children's Hospital, etc. 

HIRST'S OBSTETRICS 

A Text-Book of Obstetrics. By Barton Cooke Hirst, M.D., Professor of Ob- 
stetrics, University of Pennsylvania. 

HEISLER'S EMBRYOLOGY 

A Text-Book of Embryology. By John C. Heisler, M.D., Professor of Anatomy, 
Medico-Chirurgical College, Philadelphia. 



NOW READY, VOLUMES FOR 1896,1897,1898. 



% 



S-A-TXZtsTIDIEilR/S' 

AMERICAN YEAR-BOOK OF MEDICINE and SURGERY, 

Edited by GEORGE M. GOULD, A.M., M. D. 
Assisted by Eminent American Specialists and Teachers. 



^ Notwithstanding the rapid multiplication of medical and surgical works, 

© still these publications fail to meet fully the requirements of the general physician, 55 

^ inasmuch as he feels the need of something more than mere text -books of well- Sj 

g known principles of medical science. Mr. Saunders has long been impressed ^ 

if with this fact, which is confirmed by the unanimity of expression from the pro- ^ 

jS fession at large, as indicated by advices from his large corps of canvassers. ~ 

05 This deficiency would best be met by current journalistic literature, but most SJ 

"oe practitioners have scant access to this almost unlimited source of information, «. 

^ and the busy practiser has but little time to search out in periodicals the many <» 

$ interesting cases whose study would doubtless be of inestimable value in his 5 

ä practice. Therefore, a work which places before the physician in convenient ^ 

form an epitomization of this literature by persons competent to pronounce upon 3» 



The Value of a Discovery or of a Method of Treatment ^1. 



fe4 § 

» cannot but command his highest appreciation. It is this critical and judicial § 

4§ function that will be assumed by the Editorial staff of the " American Year- 

^ Book of Medicine and Surgery." <■? 

g It is the special purpose of the Editor, whose experience peculiarly qualifies «. 

§ him for the preparation of this work, not only to review the contributions to fcg 

Ä American journals, but also the methods and discoveries reported in the leading § 

fe medical journals of Europe, thus enlarging the survey and making the work * 



characteristically international. These reviews will not simply be a series of 



Cfc 



§ undigested abstracts indiscriminately run together, nor will they be retrospective » 

£ of " news " one or two years old, but the treatment presented will be synthetic £■ 

^ and dogmatic, and will include only what is new. Moreover, through expert * 

„g» condensation by experienced writers these discussions will be 

Comprised in a Single Volume of about 1200 Pages. 
The work will be replete with original and selected illustrations skilfully 
reproduced, for the most part in Mr. Saunders' own studios established for the 
purpose, thus ensuring accuracy in delineation, affording efficient aids to a right 
comprehension of the text, and adding to the attractiveness of the volume. 
Prices: Cloth, $6.50 net; Half Morocco, $7.50 net. 

W. B. SAUNDERS, Publisher, 

925 Walnut Street, Philadelphia. 



JUL 8 »898 



VOLUMES NOW READY. 

Atlas of Internal Medicine and Clinical Diagnosis. By 

Dr. Chr. Jakob, of Erlangen. Edited by Augustus A. 
Eshner, M.D., Professor of Clinical Medicine in the Phila- 
delphia Polyclinic ; Attending Physician to the Philadelphia 
Hospital. 68 colored plates. Cloth, $3.00 net. , 

Atlas of Legal Medicine. By Dr. E. von Hofmann, of 
Vienna. Edited by Frederick Peterson, M.D., Clinical 
Professor of Mental Diseases, Woman's Medical College, New 
York; Chief of Clinic, Nervous Dept., College of Physicians 
and Surgeons, New York. With 120 colored figures on 56 
plates, and 193 half-tone illustrations. Cloth, $3.50 net. 

Atlas of Diseases of the Larynx. By Dr. L Grünwald, 
of Munich. Edited by Charles P. Grayson, M.D., Lec- 
turer on Laryngology and Rhinology in the University of 
Pennsylvania ; Physician-in-Charge, Throat and Nose Depart- 
ment, Hospital of the University of Penna. With 107 colored 
figures on 44 plates, and 25 text-illustrations. Cloth, $2.50 net. 

Atlas of Operative Surgery. By Dr. O. Zuckerkandl, of 
Vienna. Edited by J. Chalmers DaCosta, M.D., Clinical 
Professor of Surgery, Jefferson Medical College, Philadelphia ; 
Surgeon to the Philadelphia Hospital. With 24 colored plates, 
and 217 illustrations in the text. Cloth, $3.00 net. 

Atlas of Syphilis and the Venereal Diseases. By Prof. 
Dr. Franz Mracek, of Vienna. Edited by L. Bolton 
Bangs, M.D., late Professor of Genito-Urinary and Venereal 
Diseases, New York Post-Graduate Medical School and Hos- 
pital. With 71 colored plates from original water-colors by 
A. Schmitson. Cloth, $3.50 net. 



IN PREPARATION- READY SOON. 

Atlas of External Diseases of the Eye. By Dr. O. Haab, 
of Zurich. Edited by G. E. DE SchweiniTZ, M.D., Profes- 
sor of Ophthalmology, Jefferson Medical College, Philadel- 
phia. With 100 colored illustrations. 

Atlas of Skin Diseases. By Prof. Dr. Franz Mracek, of 
Vienna. With «So colored plates from original water-colors 
by A. Schmitson. 



